History of Pain in the Surgery Ward

Taking a thorough pain history is the most important first step in the assessment of any surgical patient. The quality of this history often determines the diagnosis before any investigation is ordered. A well-structured mnemonic keeps the process systematic.

The SOCRATES Framework

SOCRATES is the standard mnemonic used across surgical and emergency settings:

Letter	Aspect	Key Questions
S	Site	Where exactly is the pain? Point to it with one finger. Is there more than one site?
O	Onset	When did it start? Was it sudden or gradual? What were you doing at the time?
C	Character	What does it feel like? Sharp, stabbing, burning, dull, colicky, cramping, crushing?
R	Radiation	Does it spread or move anywhere (shoulder, back, groin, jaw)?
A	Associations	Any nausea, vomiting, fever, change in bowel/urinary habits, bleeding?
T	Time course	Is it constant or intermittent? Getting better, worse, or the same? Any periodicity?
E	Exacerbating/Relieving factors	What makes it worse (eating, movement, breathing, coughing)? What helps (rest, antacids, position)?
S	Severity	Score it 0-10. Does it wake you from sleep? Does it stop you from normal activities?

Additional Dimensions for Surgical Patients

Beyond SOCRATES, the surgical context demands extra detail:

1. Progression and Pattern

Acute vs. chronic: Did it begin suddenly (perforation, volvulus) or build gradually (obstruction, malignancy)?
Colicky vs. constant: Colicky pain (comes and goes in waves) suggests hollow viscus obstruction (bowel, ureter, biliary); constant pain suggests peritoneal irritation or ischemia.
Breakthrough / intermittent / background: Barash's Clinical Anesthesia classifies acute pain this way - this guides analgesic prescribing.

2. Character Clues in Surgery

Visceral pain (dull, poorly localized, midline) - originates from hollow organs; the patient often cannot point to a precise location.
Somatic / peritoneal pain (sharp, well-localized, worsened by movement or coughing) - indicates peritoneal involvement; this is the pain of peritonitis.
Referred pain - right shoulder tip suggests diaphragmatic irritation (free gas, bile, blood); back pain from a pulsatile mass suggests aortic aneurysm.
Neuropathic pain (burning, shooting, allodynia) - suggests nerve injury or post-surgical nerve entrapment.

3. Relationship to Food, Bowels, and Micturition

Pain worse after eating + jaundice: biliary/pancreatic pathology.
Pain relieved by eating: duodenal ulcer (classically).
Pain worse with defecation + rectal bleeding: colorectal pathology.
Loin-to-groin pain + haematuria: ureteric colic.

4. Analgesic History

From the clinical anesthesia literature, always document:

Response to analgesics previously tried (including opioids, NSAIDs, paracetamol)
Attitudes and concerns about opioids
Oral morphine equivalent (OME) if the patient is on regular analgesia
Response to other interventions (heat, position, physio)

5. Interference with Function

Can the patient walk, eat, sleep, cough (important post-operatively)?
Does pain limit respiratory effort - critical after thoracic or upper abdominal surgery, as inadequate pain control leads to retention of secretions and pneumonia.

Contextualizing to the Surgical Ward

When clerking a new surgical admission or reviewing a patient post-operatively:

Pre-operative patient:

Duration and progression of pain (acute abdomen? chronic surgical disease?)
Previous similar episodes
Past surgical history (adhesions, stomas)
Relevant medications (steroids, anticoagulants, NSAIDs - these can mask peritoneal signs)

Post-operative patient:

Expected post-operative pain vs. new or worsening pain
Is pain at the wound site, deep in the abdomen, or referred?
Any new features since surgery (fever, increasing pain despite analgesia = anastomotic leak, abscess, hematoma)?

As stated in Barash's Clinical Anesthesia: "Pain is what a patient says it is" (attributed to Dr John Bonica, the father of pain medicine). The best way to begin assessing a patient's pain is to ask about it and listen to the answers.

Pain Severity Scales Used in the Ward

Numerical Rating Scale (NRS): 0 = no pain, 10 = worst imaginable pain. Simplest and most widely used.
Visual Analogue Scale (VAS): A 10 cm line the patient marks.
Wong-Baker FACES Scale: For patients with communication difficulties, cognitive impairment, or children.
Verbal Descriptor Scale: None / mild / moderate / severe.

Reassessment after each intervention is mandatory. Effective treatment of acute pain requires assessment as well as vigilant reassessment to determine if the primary goals are met. - Barash's Clinical Anesthesia, 9th Ed.

Red Flags in a Surgical Pain History

These demand immediate senior review:

Sudden onset, severe pain ("worst pain of my life") - perforation, AAA rupture, aortic dissection
Pain out of proportion to examination findings - mesenteric ischemia
Pain in a post-operative patient uncontrolled by usual analgesia - early complication
Fever + escalating pain - septic source
New radiation of pain to the back - retroperitoneal process (pancreatitis, AAA)
Peritonitic signs (guarding, rigidity, rebound) on examination

Summary Framework

SOCRATES  +  Analgesic history  +  Functional impact  +  Surgical context (pre/post-op)

A structured pain history in the surgical ward is not just about comfort - it is the primary diagnostic tool and directly guides the decision to operate, observe, or investigate further.

Sources: Barash, Cullen & Stoelting's Clinical Anesthesia 9e (pp. 4663-4664); Tintinalli's Emergency Medicine; Fischer's Mastery of Surgery 8e; Wikipedia - SOCRATES; Geeky Medics SOCRATES guide

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