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Surgical History and Physical Examination


I

Introduction and Initial Contact

  • 1.

    The history and physical examination are an integral aspect of patient care. Many diagnoses can be confirmed or refuted with a carefully obtained history. The physical examination can also direct further need for other diagnostic modalities such as imaging and serologic tests. During this initial encounter, the surgeon also establishes a patient-doctor relationship, which is essential to patient care. In the trauma patient, constant reevaluation must be performed to discover new findings, as well as to evaluate the course of previously noted findings.

  • 2.

    KISS mnemonic : k nock, i ntroduce yourself, s crub your hands, s it down.

  • 3.

    Ensure the patient is at ease. Close the door to protect patient privacy. Establish rapport with the patient and, if present, family and loved ones. Minimize any environmental distractions.

  • 4.

    Start with open-ended questions and listen to the patient. They will often cover most of the relevant facts. Then transition to focused and close-ended questions to obtain smaller details. Ask the patient about his/her goals of care so that they may be addressed properly.

  • 5.

    For non-English-speaking patients, a certified translator should be used. Focus your attention on the patient and not on the translator, if this is the case.

II

History

A

Chief Complaint

  • 1.

    The patient’s reason for hospital or clinical visit, in his/her own words in quotations

B

History of Present Illness

  • 1.

    Relevant details surrounding the chief complaint

  • 2.

    OLD CARTS mnemonic: o nset, l ocation/radiation, d uration, c haracter, a ggravating factors, r elieving factors, t iming, s everity.

    • a.

      Onset : When did it start? Was it gradual or sudden onset? What were you doing when it began? Have you experienced any similar episodes in the past?

    • b.

      Location/radiation : Where is it located? Is it focal or diffuse? Does it radiate? Has it migrated over time?

    • c.

      Duration : How long has it been going on?

    • d.

      Character : How would you describe your complaint?

    • e.

      Aggravating factors : What makes it worse? Position? Movement? Eating?

    • f.

      Relieving factors : What makes it better? Position? Movement? Eating?

    • g.

      Timing : Has it changed over time? Does it come and go, or is it persistent? How frequently?

    • h.

      Severity : How would you rate it on a scale of 1 to 10, with 10 being the worst? Is it always at that severity, or has it changed over time?

C

Review of Systems

  • 1.

    Yes-or-no questions that further direct the history of present illness toward a specific diagnosis. Currently, 14 systems are recognized.

  • 2.

    Constitutional: fevers, chills, weight loss, night sweats, fatigue

  • 3.

    Eyes : visual changes, eye pain, diplopia, scotomas, floaters

  • 4.

    Ears, nose, mouth, throat: epistaxis, ear pain, tinnitus, toothache, sore throat

  • 5.

    Cardiovascular: chest pain, dyspnea, orthopnea, palpitations, claudication

  • 6.

    Respiratory: wheezing, cough, dyspnea, hemoptysis

  • 7.

    Gastrointestinal : abdominal pain, nausea, emesis, diarrhea, constipation/obstipation, hematemesis, hematochezia, melena, tenesmus

  • 8.

    Genitourinary : dysuria, hematuria, urgency, nocturia, vaginal discharge, pain

  • 9.

    Musculoskeletal : pain, stiffness, joint swelling, limited range of motion

  • 10.

    Integumentary : rash, pruritus, lesions, wounds, erythema, tumors

  • 11.

    Neurologic : headache, paresthesias, numbness, weakness, poor balance, changes in senses

  • 12.

    Psychiatric : depression, changes in sleep patterns, anxiety, paranoia, mania, suicidal or homicidal ideation

  • 13.

    Endocrine : lethargy, hyperactivity, palpitations, tremor, fatigue

  • 14.

    Hematologic/lymphatic : anemia, petechiae, purpura

  • 15.

    Allergic/immunologic : lymphadenopathy, allergic response to offending agents, anaphylaxis

D

Allergies

  • 1.

    Offending agents and medications

  • 2.

    Specific reactions to these medications (e.g., rash/hives, stridor, anaphylaxis)

E

Medication

  • 1.

    Medication name, timing, and dosage

  • 2.

    Duration if relevant (e.g., antibiotics)

F

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