2 - Surgical history and documentation

Summary

Surgical history

Introduction

Age

Occupation

Presenting complaint (PC)

1. • Symptom 1 duration

2. • Symptom 2 duration

3. • Symptom 3 duration

History of presenting complaint (HPC)

1. • Quality: what, where and how

2. • Quantity: how much and impact on life

3. • Time line: duration, onset, progression, offset • Associated features, risk factors and complications

Past medical history (PMH)

1. • Similar problems in the past

2. • Medical history: MJTHREADS (MI, jaundice, TB, hypertension, rheumatoid, epilepsy, asthma/COPD, diabetes, surgery or strokes)

3. • Anaesthetic history

4. • General risk factors: stroke, ischaemic heart disease, angina, shortness of breath, COPD, renal failure, diabetes, change in bowel habit, DVT, PE

5. • Women: last menstrual period (LMP), vaginal bleeding or discharge, pregnancies, deliveries

Past surgical history (PSH)

1. • Open surgery

2. • Laparoscopy

3. • Endoscopy/endovascular procedures

4. • Ultrasound/CT/MRI imaging

5. • Surgical fitness assessment: mobility, able to climb one flight of stairs, ability to lie flat, maximal exercise distance

6. • Bleeding risk: bleeding disorders

Drug history (DH)

1. • Allergies

2. • Regular medications

3. • Medications taken since symptoms have started

4. • Anticoagulant or antiplatelet agents: warfarin, heparin, aspirin, clopidogrel

5. • Recreational drugs

Social history (SH)

1. • Smoking

2. • Alcohol

3. • Home + 3 others (work, social, personal)

Family history (FH)

1. • Relevant hereditary conditions

2. • Exposure to any risk factors of acquired disease

Systems review (SR)

1. • Systems review if not already undertaken

Summary of findings and confirmation that they are correct

Any questions? Any concerns?

Inform patient of future plans

Proceed to examination

Examination notes

What is the purpose of the history?

1. • The primary aim of the history is to establish a list of differential diagnoses based on the patient's history of presenting complaint and risk factors.

2. • The second aim is to determine the patient's medical, social and functional background, which would guide further therapy and management.