Surgical
history
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; it
is 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 it
has 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, it
is 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.