Surgery Definition – How to take surgical history?
Surgery Definition – How to take surgical history?
Surgical history is straight to the point. The most important features of surgical history are to elicit the history of pain which can be identified by the mnemonic SOCRATES. The things that need to be mentioned include sites of the pain, onset of the pain either it is sudden or slow, character of the pain such as colicky, sharp, dull, cramping or burning, the radiation of the pain, the relieving factors such as changes in posture, vomiting, analgesia and the present of the associated symptoms as well as the timing of the pain either it is constant or intermittent and exacerbating factors such as coughing, movement or changes in posture.
It is vital to ask any accompany symptoms and signs such as fever, lethargy, headache, palpitation (signs of anemia), rigors, nausea, vomiting, hematemesis, anorexia, constipation, diarrhea and per rectum bleeding,
Severity of the pain need to be quantified from the scale of 1 ( normal ) to 10 ( worst pain ).
Past medical history includes any cases of diabetes mellitus or hypertension which is important also for the anesthetist in surgical setting.
Past surgical history may include any history of previous surgical procedure performs such as previous history appendectomy may be useful to rule out appendicitis as the cause of acute abdomen or previous laparoscopy which predispose the patient to small bowel obstruction due to adhesion.
Past medication history may focus on the history of anticoagulants usage such as warfarin or aspirin that need to discontinue pre operative.
Social history will focus on smoking or alcohol intake as well as any intake of recreational drugs.
Family history will be directed to the history of inflammatory bowel disease or familial adenomatous polyposis.
Surgical history is straight to the point. The most important features of surgical history are to elicit the history of pain which can be identified by the mnemonic SOCRATES. The things that need to be mentioned include sites of the pain, onset of the pain either it is sudden or slow, character of the pain such as colicky, sharp, dull, cramping or burning, the radiation of the pain, the relieving factors such as changes in posture, vomiting, analgesia and the present of the associated symptoms as well as the timing of the pain either it is constant or intermittent and exacerbating factors such as coughing, movement or changes in posture.
It is vital to ask any accompany symptoms and signs such as fever, lethargy, headache, palpitation (signs of anemia), rigors, nausea, vomiting, hematemesis, anorexia, constipation, diarrhea and per rectum bleeding,
Severity of the pain need to be quantified from the scale of 1 ( normal ) to 10 ( worst pain ).
Past medical history includes any cases of diabetes mellitus or hypertension which is important also for the anesthetist in surgical setting.
Past surgical history may include any history of previous surgical procedure performs such as previous history appendectomy may be useful to rule out appendicitis as the cause of acute abdomen or previous laparoscopy which predispose the patient to small bowel obstruction due to adhesion.
Past medication history may focus on the history of anticoagulants usage such as warfarin or aspirin that need to discontinue pre operative.
Social history will focus on smoking or alcohol intake as well as any intake of recreational drugs.
Family history will be directed to the history of inflammatory bowel disease or familial adenomatous polyposis.
