How to take a surgical history
We will now describe how to take a surgical history. Surgeons have to take good histories too. As with all medical history taking ..
Listen to your patient, he is telling you the diagnosis”. Dr William Osler (1849-1919)
.. and 90% of the diagnosis is in the medical history. Full stop.
In surgery, careful examination is mandatory after a careful history, especially if the patient is in pain. Do not shy away from doing a rectal examination if required.
Remember abdominal anatomy is different in different people. The descending colon and appendix may be on the left, for example.
It is important to ask questions about all of the GI tract (do not restrict it to upper or lower GI) and urinary and reproductive systems (“could you be pregnant?” should be asked of all women of child-bearing age). These questions can be used in a clinical or examination setting.
Pre-introduction observation (before questions)
Before you start, stop, slow down and think. Just for 15 seconds.
Right. Antennae up. Observe the patient and environs around the patient. Why?
Observation is 90% of medicine”
What can you see? What’s their biological age? Walking pace? How are they dressed (and why)? What are they reading (and why)? Are they in pain (from where)? What’s their mood? Are they short of breath or have ankle swelling (fluid overloaded)?
Wash hands. Now you can ask questions. Clock on. Here we go ..
How to take a surgical medical history
These are ten questions you can ask, and the words to use. They can be asked in ten minutes.
1. Introduction – Start with a handshake. “Hello, my name is XX and I’m a student doctor YY. You are Mr/Mrs ZZ and you are AA years old. Is that correct?” You can ask date of birth but that takes longer and you have to do mental arithmetic to calculate the age. The handshake is also a diagnostic tool. Do they have a tremor? Red palms?
2. PC – “What is the current problem?” Listen very (very) carefully. The diagnosis is often in the patient’s first few words. Write it down. Come back to that at the end.
3. HPC – “Please tell me more about the problem”. Ditto.
Some GI symptoms are vague and not that specific to GI disease, e.g. abdominal discomfort, itching, nausea and vomiting. Though some are ‘red flag symptoms’ (e.g. rectal bleeding or change in bowel habit for more than three weeks).
A sudden onset of abdominal pain, tenderness or reluctance to move, is highly suggestive of surgical pathology. A surgeon must leave the patient asking themselves, does the patient need an operation? And if so, should that be today?
To save time, ask relevant questions from systems review here. These include questions about bowel habit, urination, and periods in a woman. Again, ask yourself ‘could this lady be pregnant?’
It may be important to ask about mood, sleep and anxiety, and do a limited mental health assessment. Some GI symptoms are due to psychosomatic disease.
4. PSH – “What major operations have you had?”. You are especially interested in GI surgery (e.g. for cancer, diverticular disease or inflammatory bowel disease).
Clearly past surgical history is very important in a surgical history – e.g. the current abdominal pain could be due to previous operation (adhesions?).
5. PMH – “Have you ever had .. diabetes (NASH?), jaundice (important, e.g previous Hepatitis A, B and C), anaemia, tuberculosis, heart attacks, strokes, high blood pressure, epilepsy, rheumatic fever, or ulcers in your tummy?”
Specific GI questions include: “do you have Crohn’s disease, ulcerative colitis, diverticular disease or bowel cancer?”
You need to have finished PMH by 5 mins
6. Drugs/Allergies – “Please show me a list of your current medication? And have you had a major allergic reaction to any medication?”
The medication history is important in surgical histories as well as medical – e.g. to pick up hepatic drug side-effects. You need to take it carefully.
Another example is immunosuppression. Steroids are well known to mask surgical disease. And the frail elderly may not mount a raised white count. This is why a CRP is useful.
7. SH – “Are you married, how many children have you had, and what is/was your current/last job?”
Occupation is relevant for GI disease, especially hepatic. Certain professions are known for high alcohol use: armed services, publicans, journalists, lawyers, dentists and doctors! So you should ask about current and all previous jobs. Alcohol is a key cause of alcohol-related hepatitis and pancreatitis.
You should also ask about other risk factors for liver disease (Hep B, C and HIV): recreational drugs, and non-heterosexual activity, e.g ” have you ever taken recreational drugs (if yes, have you ever injected into a vein?) or had sex with someone of the opposite sex?”
8. SH – “Have you ever smoked, and have you ever been a regular heavy drinker?”
If there is any hint of excess alcohol use, take a precise alcohol history (units per day, binge or not etc), including CAGE questions.
9. FH – (depending on age of patient) “Are your parents alive fit and well? OR “Are your parents still with us?” Depending on answer, “what did they die of?” OR “What did your parents die of?” AND “Are there any diseases that run in the family?”
“Has anyone in your family ever had stomach, bowel or liver problem?” (e.g. polyposis coli)
“Has anyone in your family had any funny or rare diseases?” (autoimmune, e.g. Crohn’s disease and ulcerative colitis).
You need to have finished SH/FH by 8 mins, to give time for ..
10. ICE – “What are your ideas about what’s going on, and what are your concerns and expectations (of us)?” This also gives time for you to think what have you forgotten .. did you ask about medication/allergies and/or smoking/alcohol? What was the date of the last menstrual period (LMP; did you write it down)?
At this point, the patient may give you crucial information like a past history of irritable bowel syndrome (IBS), recurrent UTIs, Crohn’s disease, ulcerative colitis, diverticular disease or bowel cancer; if it has not come out on previous questioning.
Summary
We have described how to take a surgical history. The past surgical and alcohol history is important. We hope you have found it useful. Like all history taking, the only way to get good at it, is to practice alot (alot).
Last Reviewed on 15 January 2024