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    HX Taking Surgery

    Uploaded by

    Syimah Umar
    The document provides a template for taking a patient's surgery history. It includes sections for collecting information on the patient's personal details, presenting complaints, review of symptoms organized by body system, past medical history, family history, social history, and drug history. The goal is to gather relevant clinical information in a structured format to aid clinical decision making for the patient's presenting issue.

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    Download as DOCX, PDF, TXT or read online from Scribd

    HX Taking Surgery

    Uploaded by

    Syimah Umar
    44 views1 page
    The document provides a template for taking a patient's surgery history. It includes sections for collecting information on the patient's personal details, presenting complaints, review of symptoms organized by body system, past medical history, family history, social history, and drug history. The goal is to gather relevant clinical information in a structured format to aid clinical decision making for the patient's presenting issue.

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    hx taking surgery

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    The document provides a template for taking a patient's surgery history. It includes sections for collecting information on the patient's personal details, presenting complaints, review of symptoms organized by body system, past medical history, family history, social history, and drug history. The goal is to gather relevant clinical information in a structured format to aid clinical decision making for the patient's presenting issue.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    44 views1 page

    HX Taking Surgery

    Uploaded by

    Syimah Umar
    The document provides a template for taking a patient's surgery history. It includes sections for collecting information on the patient's personal details, presenting complaints, review of symptoms organized by body system, past medical history, family history, social history, and drug history. The goal is to gather relevant clinical information in a structured format to aid clinical decision making for the patient's presenting issue.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
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    Surgery history taking

    Patient details Disturbances of smell, vision or hearing


    Full name Headache
    Address Change of behaviour
    Sex MS Pain in joints
    Age K Swelling in joints
    Ethnic Limitation of movement
    Marital status Muscle pain
    Occupation Muscle weakness
    Date of admission Disturbance of gait
    Date of clerking GUS Frequency of micturition
    Hesitancy
    Presenting complaint Poor stream
    If more than 1 sx, list them in order in which they are Dysuria
    most troublesome to the patient Color of urine – haematuria
    Thirst
    HOPI Polyuria
    Full details of the main complaint or complaints Symptoms of uraemia – headache,
    Ask other sx related to the abnormal system drowsiness, fits, vomiting, peripheral oedema
    mentioned Loin pain
    Date of menarche or menopause
    Systemic review Menstruation
    GIT Appetite Dysmenorrrhea
    Change in diet/weight Previous pregnancy and their complications
    Nausea Breast symptoms – pain, lumps
    Difficulty in swallowing Impotence
    Regurgitation Dyspareunia
    Heartburn
    Flatulence Past medical history
    Indigestion Previous illness
    Vomiting – character of vomiting (coffee Operations/accidents
    grounds, blood, bile, faeculent Diabetes
    Abdominal pain Rheumatic fever
    Abdominal distension Tuberculosis
    Change in bowel habit – character of stool Asthma
    Rectal bleeding Hypertension
    Change of skin – pallor, anemia, jaundice STD
    RES Cough
    Sputum – purulent, haemoptysis Family history
    Dyspnoea Cause of death of close relatives – parents, brothers
    Wheezing sisters
    Hoarseness Cvs and malignancy
    Chest pain Familial illness – polycystic kidney disease
    CVS Chest pain
    Dyspnoea Social history
    PND Occupation
    Orthopnoea Housing
    Palpitation Travel abroad
    Ankle swelling Leisure activities
    Cough Marital status
    Dizziness Sexual habits
    Intermittent claudication Smoking, drinking, eating habits
    Rest pain
    Temperature/color changes of hands and feet Drug history
    Oedema Steroids, anticoagulation and contraceptive pill
    CNS Blackout Drug abuse
    Fits Allergies - antibiotics
    LOC
    Fainting attacks
    Tremor
    Weakness of limbs
    Paraesthesia

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