The history of the complaint is the key step in surgical diagnosis. It will vary according to the complaint, and be specific for particular complaints or systems. Such specific histories will be acquired as the particular surgical speciality is studied. There is no such thing as a standard surgical history as there is in medicine; itis for this reason that the student often adapts the medical history to the surgical clerking and misses many of the important points that are required in surgical decision making; thus, as the subject is studied, the form of history is acquired.
There are two types of history in surgical practice. The first is the outpatient or emergency room history in which the specific complaint of the patient is pinpointed; the second is the clerking of a patient admitted for elective surgery. The object of the first history is to obtain a diagnosis on which the treatment is ordered, whereas the second is to assess that the treatment planned is correctly indicated and to ensure that the patient is suitable for that operation.
Invariably the surgical patient presents in the out-patient department or the emergency room with a special problem such as pain or a lump. As opposed to most medical histories, the patient’s story is limited and frequently the surgeon will focus the detail of the history, by a few specific questions. It is important to know when the symptom started, how ithas progressed, whether there are associated features and whether the symptom is improving or getting worse. Time can be important, as are relationships to other symptoms. The effect of any treatment on the symptom is of value. Once the symptom complex has been resolved and clarified, the general health of the patient is defined to determine whether the complaint is local or part of a general disease. Questions are asked related to previous illness or concurrent illness, drug therapy, allergies and complications related to anaesthesia, to compose a picture of the patient’s general status and determine suitability for treatment. The surgical history is a dynamic event, in that the pattern of questioning will change according to the answers of the patient, to compose the picture of that patient’s illness.
The clerking history centres on direct questioning of the patient about specific points related to the complaint. For instance, itis important to record the symptoms of prostatism in the patient having prostatic surgery, so that these can easily be compared with the postoperative state to assess the effect of the surgical procedure. Further, in the patient who is referred by a physician for surgery, specific questions related to the indications for surgery are asked, and the surgeon decides whether or not the patient will benefit from the operation; this is particularly important in noncancerous conditions where continued medical management is an option.
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