Surgical History Taking — Complete Format

1. PATIENT IDENTIFICATION (Biodata)

• Name
• Age — important for age-related conditions (pediatric surgical issues, elderly comorbidities)
• Sex — relevant to sex-specific conditions (e.g., inguinal hernia in males, breast pathology in females)
• Occupation — exposure risks, functional demands post-op
• Address / Residence — epidemiological relevance
• Religion / Marital status — consent, blood transfusion refusal (Jehovah's Witnesses)
• Date of admission
• Informant — reliability of history

2. CHIEF COMPLAINT (CC)

• The single most prominent symptom in the patient's own words
• Duration stated alongside (e.g., "abdominal pain for 2 days")

3. HISTORY OF PRESENTING ILLNESS (HPI)

Associated Symptoms (Surgical-Specific)

• Constitutional: Fever, chills, rigors, night sweats, weight loss, loss of appetite (anorexia), fatigue
• GI tract: Nausea, vomiting (nature — bilious, feculent, blood), dysphagia, odynophagia, heartburn, hematemesis, melena, hematochezia, change in bowel habits, constipation, diarrhea, tenesmus, jaundice (obstructive vs. hepatic), mucus/blood in stool
• Urinary: Dysuria, frequency, urgency, hematuria, hesitancy, poor stream, nocturia, retention, incontinence
• Vascular: Claudication distance, rest pain, non-healing ulcers, color changes in limbs, swelling
• Breast: Lump, pain, nipple discharge, skin changes (peau d'orange), nipple retraction
• Hernias/Lumps: Site, size, duration, reducibility, irreducibility, pain, change in size with coughing/standing
• Thyroid/Neck lumps: Swallowing difficulty, hoarseness, pressure symptoms, palpitations, heat intolerance, tremors
• Trauma: Mechanism, time since injury, first aid given

4. PAST MEDICAL HISTORY (PMH)

• Previous similar illness — was it diagnosed? Treated?
• Known medical conditions: Diabetes mellitus, hypertension, asthma, cardiac disease, epilepsy, tuberculosis, HIV/AIDS, peptic ulcer, coagulation disorders, malignancy
• Previous hospitalizations
• Medications currently taken (relevance to surgery/anaesthesia — anticoagulants, steroids, antihypertensives, oral contraceptives, insulin)

5. PAST SURGICAL HISTORY (PSH)

• Previous operations — type, when, where, outcome
• Anaesthesia history — any complications (malignant hyperthermia, awareness, difficult intubation, post-op nausea)
• Post-operative complications — wound infection, dehiscence, DVT, bleeding
• Implants / Prostheses — joint replacements, pacemakers, vascular grafts, mesh

6. DRUG HISTORY

• Current medications with dose and duration
• Specifically ask about:
  • Anticoagulants (warfarin, heparin, NOACs) — bleeding risk
  • Antiplatelet agents (aspirin, clopidogrel)
  • Steroids (adrenal suppression risk)
  • NSAIDs (renal, gastric, bleeding concerns)
  • Oral contraceptive pill (DVT risk)
  • Insulin / Oral hypoglycaemics (perioperative glucose management)
  • Antihypertensives / Diuretics
  • Herbal / Over-the-counter medications

7. ALLERGY HISTORY

• Drug allergies — name the drug, describe the reaction (rash, anaphylaxis, angioedema)
• Latex allergy — important intraoperatively
• Food allergies
• Contrast dye / Iodine allergy — relevant for imaging/procedures

8. FAMILY HISTORY (FH)

• Similar conditions in family (hereditary cancers, polyposis syndromes, MEN syndromes)
• Anaesthetic complications in family (malignant hyperthermia is autosomal dominant)
• Coagulation disorders (haemophilia)
• Diabetes, hypertension, heart disease

9. SOCIAL HISTORY (SH)

• Smoking: Current/ex-smoker, pack-years — affects wound healing, pulmonary reserve, anesthetic risk
• Alcohol: Units per week — liver function, coagulation, withdrawal risk
• Recreational/IV drugs: Vascular access issues, infection risk (HIV, hepatitis B/C)
• Occupation: Physical demands, exposure hazards
• Living situation: Who lives at home? Ability to self-care post-discharge
• Exercise tolerance / Functional capacity — in METs (can they climb a flight of stairs? Walk on flat ground?)
• Diet: Nutritional status — malnutrition impairs wound healing

10. SYSTEMIC REVIEW (SR)

11. OBSTETRIC & GYNAECOLOGICAL HISTORY (Female patients)

• LMP (last menstrual period) — pregnancy must be excluded before surgery/anaesthesia/X-ray
• Gravida/Para status
• Menstrual history — regular/irregular, dysmenorrhoea, menorrhagia
• Contraception — OCP increases DVT risk
• Previous gynaecological procedures — LSCS (scar anatomy important), D&C, hysterectomy

12. NUTRITIONAL ASSESSMENT (Surgical-specific)

• Recent weight loss (>10% in 6 months is significant)
• Appetite, dietary intake
• BMI (obesity — anaesthetic challenge, wound complications; cachexia — poor healing)
• Signs of malnutrition: muscle wasting, oedema, angular stomatitis

13. ANAESTHETIC RISK ASSESSMENT (Integrated from history)

• ASA Physical Status Classification (I–VI)
• Mallampati score predictors from history (neck mobility, mouth opening)
• Cardiac risk — RCRI (Revised Cardiac Risk Index) factors
• Respiratory risk — CPET (cardiopulmonary exercise testing) indication

Summary Format for Surgical Clerking

"Mr./Mrs. X, a [age]-year-old [male/female], [occupation], presents with [chief complaint] of [duration]. He/She gives a history of [HPI summary]. Past medical history includes [PMH]. Past surgical history includes [PSH]. Currently on [medications]. No known drug allergies / Allergic to [drug — reaction]. Family history of [FH]. Socially, he/she [smoking/alcohol/occupation/support]."

• Always ask about previous surgery on the same site (adhesions, recurrence risk)
• Never omit anticoagulant history — critical for perioperative management
• Functional capacity (METs) is the single best predictor of perioperative cardiac risk
• LMP is mandatory in all females of reproductive age before any procedure
• Ask about implanted devices (pacemakers — diathermy contraindication; metal implants — MRI)