Surgery history taking

SURGERY HISTORY HISTORY TAKING SURGERY • Greet the examiner. • Greet the patient. Presenting complaint. • How may I help you today? • What brings you today? ODIPARA: Onset Duration Proyection Precipitating Reliving • • • •

How did it start? How long? Did it get better or worse? Did you did anything to alleviate it?

• • • •

Where exactly is the pain? How bad is the pain? How will you describe your pain? Does this pain go anywhere else?

PAIN

P2: Past History: Medical, Surgical, Previous similar complaints. • •

Have you undergone surgery before? Has this complaint happened before?

RULE OUT DIFFERENTIAL DIAGNOSIS P3: PERSONAL HISTORY Ask: Smoking. Alcohol. Drugs. Sleep. Appetite. Weight. Bladder/Bowel. • • •

Have you ever smoked before? Do you smoke cigarettes? How long? How many? Do you drink alcohol? How long? How much? By any chance do you take any recreational drugs.

• • • •

How is your sleep? Have you noticed any change in your appetite? In your weight? Is there any problem when you passed water? Is there any problem when you passed bowel?

PERIODS PILLS Pregnancy PAP Smear: Have you undergone your PAPsmear before? What were the results?

MAFTOSA

Medication: Are you taking any long term medications? Including over the counter medication for any particular condition Allergy: Are you allergic to any medication?

Family history: Family History of similar conditions. Travel History: Have you recently travelled outside of UK? Occupational history : What do you do for a living? Social History: Family, Friends. A: ANYTHING ELSE.

END OF STATION Thank you very much Mr. You have been cooperative. I would like to speak the examiner now. Examiner: My most probable diagnosis is ....... I have ruled out ..........

Dysphagia D/D: • • • • • • •

Ca Esophagus. Achalasia Oesophageal stricture Pharyngeal pouch Myasthenia Gravis Globus Histericus Post-procedural

CA Eosophagus: Difficulty on solid >liquid. Weight loss. Appetite loss. Anaemia. Smoking History. Achalasia Cardia: Difficulty on liquid >Solid.

Oesophageal Stricture: Due to esophagitis. Drinking hot liquid (Corrosive material: Bleach, househo cleaner). Is it possible that accidentally you swallowed something corrosive or hot? Pharyngeal pouch: • How much do you feel about your mouth odour recently? • Have you noticed food stuff left on pillow when you get up in the morning? • Have people told you that your odour is offensive? Myasthenia Gravis: Do you feel tired most of the day? Globus Histericus: Female patient. Do you have a sensation of lump in your throat? Do you have to clear your throat repetidly? Do you feel the need to clear your throat repetidly? Post-operative Endosocopy: Have you undergone a procedure recently in which a instrument is passed from your mouth to your tummy?

ABDOMINAL PAIN Main diagnosis:

• Acute cholescystitis : fever • Billiary Colic : No fever. • Acute Hepatitis : Viral, Alcoholic. Rule Out: Trauma. Acute Pancreatitis. PID. Renal Calculi. MI. Are you running temperature? Acute Cholecystitis: • Pain will radiate to the hip. • Does the pain Increase on taking fatty foods? • Does the pain come in episodes? Acute Hepatitis: Have you noticed a yellow discolouration of your skin? Renal Calculus: Fever. Cough. . Pain is worse as you breath. PID: Acute Cholecystitis: Pain increases in fatty foods? Any fever, vomiting, nausea? Hepatitis Tattos, recreational drugs, travel history. Not sexual history. Blood transfusions. Alcohol intake. Acute Pancreatitis: Pain radiating to the back. Is pain moving to your back? Pneumonitis: Fever, cough, pain. Gastric & Duodenal ulcer. Is this pain related to food? Increases with food: Gastric Ulcer Relieves with food: Duodenal Ulcer LOWER ABDOMINAL PAIN Male: Testicular Torsion. Acute Epidemicitis. Female: Ectopic Pregnancy. PID. Torsion. Acute Appendicitis. Acute Diverticulitis. UTI. Obstructed hernia. Urinary Bladder Calculi. Testicular Torsion: Do you have a recent onset of pain in the scrotum? Discharge from penis? Ectopic Pregnancy: Have you noticed bleeding from your vagina??? PID: Have you noticed any abnormal vaginal discharge? Ovarian torsion: Have you undergone any US scan that showed fluid filled sac in your ovaries? Acute Appendicitis: Pain will start from belly button. Hernia: Have you noticed any swelling which used to disappear before and not

anymore, and has become tender to touch? Urinary Bladder Calculi:Does the pain start midway, to neck, goes into private parts? Acute Diverticulitis: Does the pain disappear when you pass stool? Testicular Torsion • Pain increases on lifting testicles. • Pain unrelieved by any measure. Acute Epididymo-Orchitis • Fever + swelling in scrotum. • History of mumps 1 month ago or swellings. Female: EP: Last menstrual period: PID: Fever, discharge. Torsion: USG which shows Cys on ovaries. Site: Left: Acute Diverticulosis Right: Acute Appendicitis. Flank Pain: Renal Calculi From Loin to Groin Pain: Ureter Calculi Private area: Ureteric Bladder Calculi Hernia: • Have you noticed any swelling which used to disappear before and not anymore, and has become tender to touch? (Obstructed hernia) Urinary Tract Infection: 1. 2. 3. 4.

Burning sensation Fever Increase frequency Abdominal Pain

Don’t ask Hx Sexual activity.

RECTUM D/D: • • • • • • •

Hemorrhoids Anal Fissure Rectal Prolapse Ulcerative Colitis Acute Diverticulitis Post-Procedural Drug Induced

• Bleeding disorder • Liver disease Type of Blood Assess Anaemia: SOB, racing of heart. Fatigue. Bleeding Questions: • Post –surgery. • Blood thinners. • Post-procedural bleeding. Colorectal Carcinoma • • • • •

Altered Bowel habits. Change in bowel habits. Blood in stool Weight loss/Appetite loss Incomplete sense of evacuation

Family History: Family History of Medical Problem Family History of Bowel Problems Family History of Bowel Carcinoma Haemorrhoid: Painless. Bright red splash. Anal Fissure: Painful + History of constipation. Streak of blood. Ulcerative Colitis: Diarrhea and Blood. Skin and Eye changes. Acute Diverticulitis: Rule out Anaemia: • Shortness of breath • Racing of heart • Feeling tired, fatigue, dizziness, light headness • Have you done recently any procedure? • Have you been diagnosed with a condition called Polyp? • Is there any history of bleeding disorder? Are you taking any medication regularly for a long time? • Have you been diagnosed with a Liver condition?

HEMATURIA D/D: • • • • •

Renal Calculi Ureteric Calculi Bladder Calculi Urinary Tract Infection Renal Carcinoma

• Bladder Carcinoma • Schistosomiasis • Drug Induced (Warfarin/Cyclophosphamide ) • Renal Calculi: Pain Back. • Ureteric Calculi: Travels far side of tumour, deep down the private parts. • Bladder Calculi: Urine stream. Urinary Tract Infection : Burning Sensation. Renal Carcinoma: • Have you noticed any swelling in your groin area? • Weight loss. Fever. Night Sweats.

Bladder Carcinoma: • History of working in Dye Industry. • Smoking.

Schistosomiasis: Any chance of excessive swimming in lake? Any friend you joint you is having a similar complaint?

Drug Induced: Cyclophosphamide: Are you taking medication for a sinister problem? Urinary Bladder Carcinoma: Occupation: DYE INDUSTRY

Schistosomiasis: • Travel outside the UK? • Where? • Did you by any chance swim in any lake? Trauma: Is it possible that you accidentally may have hurt yourself in your private area?

URINARY OBSTRUCTION • • • • • • •

BPH Carcinoma Prostate Carcinoma Bladder Bladder Calculi Urinary Tract Infection Drug Induced Post-procedural.

• • • • •

Frequency Urgency Hesitancy Dribbling Nocturia

BPH

• Urine stream • Incomplete sense of evacuation Frequency: • Do you need to go to the toilet most of the time now? • Do you feel you have to go the toilet more often than you used to do before? Urgency: • Are you able to hold it when you go to the toilet? • Are you able to hold your urine or you feel you have to rush to the toilet? Hesitancy: • Do you have to wait a long time to go out of bathroom? • Do you find it difficult to pass urine? Nocturia : Do you wake up at night frequently to pass urine? Urine Stream : How is your urine stream? Incomplete sense of evacuation: Do you feel you cannot empty completely your bladder? CA Prostate: Systemic Symptoms: Back Pain/Bone Pain. Hematuria. Symptoms of BPH. CA Bladder: Smoking. Dye Exposure. Drug Induced: Anticholinergic drugs: Eye problems. Mood Elevation (AD-Tryciclics). • Are you taking any medication for a long term medical condition such as ... (Eye problems, Mood problems). • Are you on any long term medication? Dysuria + UO (Urinary Obstruction). Management:BPH + UTI Investigations: Blood test: PSA Urine: Dip M/C & Treatment: Antibiotics. Surgery

TESTICULAR PAIN D/D: • • • • • •

Trauma Testicular Torsion Acute Epidediomyositis-Orchitis Urinary Tract Infection Obstructive Hernia Bladder Calculi

Swelling a few days ago.

• UTI: fever. Burning sensation when passing water. • Obstructive Hernia : Have you noticed a swelling in the groin that appears and disappears and is now more permanent. Bladder Calculi Management: Dx: Torsion Testis. Acute Epidemiocystitis. Physical Exam of Privates Parts. Tests: • • • •

Blood tests. Urine tests. Swab of discharge. USG Testis.

Treatment: • Torsion of Testis: Urgent surgery. • Acute Epidemiocistitis: Analgesia. ATB. Rest.

COUNSELLING Listen + Address Patient´s Concerns 1. Opening sentence – GRIPS Dx- Given. Not Given Dx: Focus History, Establish Dx and then Counsel.

1. Do you know about this condition? He Knows: Give Compliments. 2. Explain to the patient. He doesn´t knows. 1. Address the patient´s concerns: Do you have any concerns? 2. Closing sentence: Thank you very much. If there is any concerns you have, yo can call us again o come again to the hospital.

Management Plan – MEDIAS M – Medication E - Exercise + Physiotherapist D - Diet + Dietician I - Information: Leaflets/Websites. Support Groups. Follow-up. Warning signs. A - Alcohol. Cutdown. S - Smoking. Stop. Nicotine replacement. Smoking cessation Clinics.

GOUT History Taking: SOCRATES. OEDIPARA. Questions of pain.

Where is the pain? Did you hurt your toe? Are you on long term medication? Diuretics (Watertablets) Dx with Joint Problem Do you drink beer? What is your diet preference? IN my clinical opinion: you have a medical condition called GOUT. It is a condition that occurs when a chemical reaches high level in your blood. It becomes crystal in your joint, such as your toe. • NSAID • Colchicine. • Alpurinol. Mention it even if the patient don´t ask. Have you heard about them. Prevention: • • • •

Diet: Avoid red meat, tomato, chubac. Refer dietician. Stop Diuretics: Your GP would give you some other medication. Alcohol: Cut down beer. Advice: Don´t take over counter medication without consulting your GP.

Anaemia (Herniorrahphy Cancelled). COUNSELLING. We had to postpone the planned surgery. We have done some tests with you. They show you have some condition, having anaemia. What is Anaemic? Is a condition in which the amount of blood cells is reduced in your body. Why you cannot operate? Risk of doing surgery. This is not an emergency condition, We can wait, postpone surgery. We will study and investigate the sudden drop in your blood cells. Risks associated with Surgery: • Increased risk of infection. • Poor wound healing. • Danger to your life with sleep medication. Take a FOCUS History to find cause of ANAEMIA: Malnutrition: Are you eating appropriately? Malabsorption: Malignancy: Notice any change in your weight? Medical Condition: Develop any medical condition? Such as Joint pain? Medication: Did you start on any new medication? Malaria: Travelled outside of UK. Management: Investigations: Run some tests. Treatment: Diet.

Medication: • • • •

Iron tablets. Folic Acid tablets. Vitamin B injection. Iron Injection.

We must first investigate the cause. Giving blood at this stage carries its own risk. We only give blood in urgent situations. Our HOSPITAL PROTOCOL doesn´t allow us to give blood in non-urgent situations. Work & Pension department: Case – Surgery: Days off.

Anaemia: Is a condition in which Red Blood Cells carrying O2 to tissues has gone down unexpectedly and the needs to be thoroughly investigated. There are risks: • Poor wound healing • Risk of infection • Interference with sleep medication We don’t want these to happen to you. These is why we need to defer surgery. Causes: • Are you on any long term medication? • Have you noticed any recent change in the colour of your stools? • Have you noticed anything with your urine lately? • Malignancy questions: Weight loss, fatigue. We will need to run some further investigations to find/determine the cause. Do you have any religious restriction regarding blood transfusion? We respect your beliefs, let my consultant know. We’ll be monitoring you regularly, and once you are fit we will program you for surgery immediately.

What about giving me blood? Transfusing blood in its own, has its own complications. And we will not want to put you in undue risk. We wan you to get better.

WOUND INFECTION.

I´m very sorry that are you in pain & Do you need any painkillers? My consultant is busy at the moment give me chance, I will see you now, and later arrange an appointment with a consultant. As you undergo surgery 7 days ago, this is wound infection, I am very sorry. Patient is suffering from a wound infection from surgery.

• We need to run some tests. We will take a swab from your wound. We need to find out wha exactly is causing the problem. • We will give you regular painkillers, start ATB immediately. • My consultant will see you later and guide you.

However. As we told you earlier, before doing the surgery, there is a possibility of having some complications after surgery, I am sorry, but it is one of those complications. Patient: Give some medication, I want to go home. We need to keep you in the hospital, because we have to give you ATB which most probably will be given by blood channels, which can´t be given at home. If you go outside, there is a probability that you will get more infections. Worry about wages: WORK & PENSION DEPARTMENT will compensate. I am going to inform my seniors & Infection Control Team: INFECTION CONTROL TEAM. Cure by proper Antibiotics, but everyone responds differently to medication. I am sure my colleage might have explain these unforeseen complication. But is best to focus on getting you better.We have informed the Infection Control Team and notify your consultant and are looking at this with the outmost priority. Patient: Will it be cured? It is a treatable condition with the right ATB, along with your patience and cooperation. Patient: How long will it take? As soon as your infection is cleared up, and your wound healed.

ABDOMINAL PAIN GRIPS. Explain Dx: Results all normal. No abnormality. There is no chance, we ran many cross-check to each other. So taking it in consideration will not be beneficial. Painkillers: Pain Healthy diet. Surgery. Stress: Yoga, exercise. Morphine. Hospital environment is not good for your health, why do want to put your life at risk. Sending Patient HOME: WARNING SIGNS: Come back to the hospital for study if any: • Any change in bowel habits. • Any weight loss. • Any appetite loss. NHS DIRECT NUMBER: Advice you according to the problem. Advice to go to the hospital if necessary. We do respect and regard your concern. And we will treat the symptom. Asks for admission: Action Plan: 1. 2. 3. 4.

We will not admit you, but we will keep a close eye on your symptoms with your GP. Follow-up regularly with your GP. We will prescribe you painkillers if you need some. Encourage participation in physical activities (physiotherapy).

5. 6. 7. 8.

Stress the importance of a healthy well balanced diet. Endulge in stress relieving exercises (yoga, meditation). Give information about community liason nurse. Give information about local counsellor.

Ask has anyone in your family been treated with similar problems/complaints? Answer Yes:Give warning signs of Bowel Ca: Weight loss Appetite loss Fatigue New Symptoms Please come back. Have you noticed any change in the character of pain? Whatever you have is not serious. It could be Irritable Bowel syndrome, or Abdominal migraine, but we are not sure. But we will manage it accordingly.

ULCER. SKIN • • • • • • • • • •

Where is it? How did you notice it? How long has it been there? What is the colour? Is it painful? Has the ulcer change it size? Any bleeding from discharge? How is the skin around the ulcer? Bleeding or discharge? Is this the first time you have an ulcer?

Malignant Melanoma D/D: • • • • • • •

Squamous Cell Carcinoma Basal Cell Carcinoma Diabetic Ulcer Venous Ulcer Post-traumatic T. Bulbar Pressure Sore.

Main Features: A – Asymmetrical B – Border Irregular C – Colour Malignant D – Diameter >6 cm E – Evolving change in size Squamous Cell Carcinoma: Border rugosity Pressure Sores: Have you been immobilized for a long time?

According to my clinical opinion you could have a skin problem. It may be a sinister growth. We will remove the ulcer with a few mm of surrounding normal skin. We will send the specimen for laboratory. Results will come 3-4 weeks time. Once we have the results we will know if there is normal or abnormal tissue, we will treat it according to the problem. Ulcer: • • • • • • • • • • •

Colour Site Size Shape Pain Bleed Discharge Surrounding structure Smell/odour Duration Itching sensation

Differential: • • • • • • • •

Malignant melanoma Squamous carcinoma Basal Cell Carcinoma Diabetic ulcers Venous ulcers Tuberculous ulcers Pressure sores Traumatic ulcers

Venous ulcer: Have you noticed any change in size, colour on your legs? We have a condition called Malignant melanoma. It could be sinister but we manage it. We would like to remove the ulcer. We will remove it with surrounding 5 mm of normal skin. We will send the ulcer to the lab for further investigations. Results will come back in 2-4 weeks. Once we have the results, we would know whether it contains normal or abnormal tissue and treat it accordingly. Hopefully it would not be serious. If results are not very encouraging we will do some more tests. Please don’t worry, you are in safe hands. It ALWAYS BE MALIGNANT MELANOMA.

ANKLE SPRAIN Injury to ligament (strong band of tissue, around joints, these help to keep bone together and stable? P - Painkillers R – Rest

Ankle for 2-3 days Crutches Mobile for week. I – Ice Ice pack by thin ice in towel or plastic bag, apply over ankle, reduce swelling 48-72 hours. (15 minutes/every 2 hours/48-72 hours). C – Compression bandage Limit swelling. Remove before sleep. E – Elevation Whole leg with pillow at night. AVOID: HARM H – Heat A – Alcohol R – Running M – Massage Definition: Twisting of ankle has led to overstretching of certain tissues involving ligaments and tendons, which has resulted in pain and swelling you are experiencing. PRICE: Pain: Pain killers for 3-5 days. Rest: No weight bearing for 1 week. P weight bearing for 2-3 week. Normal weight bearing for 4 weeks. Ice: 5-10 minutes/90 minutes/1-2 days. Compression: Compression bondage for 2 weeks. Elevation: Elevation of limb.

TESTICULAR LUMP Testicular implants are available, after removal of testis. So they can restore normal appearance after surgery. Can´t affect fertility if other testis is normal. Do not say its cancer. Concerns: Sex life: Doesn’t affect your sex life. Fertility: As long as your other testis is healthy should not affect your fertility. Cosmetic: We can provide a prostetic testis. Talk to my consultant and alleviate your concern.

BREAST LUMP Post-operative Options: 1. Mastectomy Bra 2. Reconstructive surgery: • Lip Modeling • Silicon Implant

• Muscular Flap 3. Excessive Regime: Actions:

3. 4. 5. 6.

• Combing your hair • Scratching your own back • Climbing walls Self-examination of the other breast – Nurses will teach her. Physiotherapy. Follow-up Leaflets, Websites.

Mastectomy bra: Gives natural appearance Exercise regime: Prevent lymphedema. Complications: Metastasis Symptoms: • • • •

Bony pain Yellow discolouration Headache Visual disturbances

SURGICAL PROCEDURE 1. 2. • • • • • • 3. • • • • • • • 4. • • • • • 5.

Opening statement. Admit patient: Nill by mouth Operation threatre. Anaesthesia. Procedure (durational incision). Recovery room. Ward Discharge Recovery at home Special Care Rest Light work Hard work Driving Sex. Complications: Pain: Painkillers. Infection: ATB Bleeding Damage to surrounding structures: Gastrointestinal: Nausea, vomiting, diarrhea. Consent form.

• Read them carefully. • Understand them. • Give consent by signing them.

UPPER GI ENDOSCOPY APPENDICECTOMY CHOLESCYSTECTOMY

NEPHRECTOMY Breaking bad news Just say hello. Are you Mr. Smith, husband of ..... I am Dr.... How much do you know about the condition of your wife? Unfortunately I don´t have good news, your wife has a condition called .... Observe reaction: Crying offer tissues. Not crying: give time. We need to remove it immediately to save the patient´s life and before it moves to other organs. Breaking bad news: Don´t give Leaflets or websites. Consent form to the patient. RADICAL NEPHRECTOMY Procedure to remove kidney and surrounding structures. There is a possibility that when we open your tummy the surrounding structures are involved by cancer. In such case we have to remove surrounding structures. It is called RADICAL NEPHRECTOMY. Nephrectomy Counsel patient husband. How much do you know about your wife’s condition? Mr.---- Let’s not think about that now. Let’s think about how to help her. My consultant has decided to do this surgery/procedure. Do you know anything about this procedure – Nephrectomy? Don’t give time frame. Cancer society McMillan Nurses Instead of Risk of Death: Say Slight risk to life during operation. Radical Nephrectomy Remove surrounding structures. We are uncertain about the future regarding its recurrence. Monitoring her regulary.

HEMICOLECTOMY

Our team has decided to remove the portion around portions of bowel by a procedure called hemicolectomy. Admit you. However, in case abnormality has spread and we will have to take large part of bowels. My consultant will create a hole in your tummy, also known as stoma, and join first part of bubble so that he can pass stools through his back passage. Specialist Stoma Nurse: Will teach you about it. Take to Recovery room. Complications of Stoma: • Herniation • Redness • Bleeding • Stoma can be seek in or out. Any problem with stoma: CALL STOMA NURSE. Avoid: • • • •

Spy food Baked beans Brocoli Coliflor

Avoid: Contact Sports Leave you with leaflets, websites, support groups. How much you know about your condition? Informed about diagnosis. Now is about procedure. Always talk about colostomy. Colostomy Sympathy, empathy. Colostomy nurse. Clean hygiene, prevent infection, Travel, diet, general activities. Almost a normal life. Diet: Avoid spicey foods, broccoli, broiled egg. Refer to dietician for advice. Avoid foods that give foul smell. Avoid contact sports. Take some precautions. Live almost a normal life. Hide ostomy. In time you will find ways to cope with it/deal with it. We’ll help you (reassurance) Travel: He cannot travel without ostomy bags. Take ostomy bag with you. Sex: It will not affect your sex life. If you have any problems you will come back to us. Discuss with people whom you trust. End will leave with a consent form. Leave leaflets, websites, support groups. Important points:

Colostomy nurse Diet General activities. Travel.

PROSTATECTOMY Waterpipe Waterbag Watertablets

VASECTOMY Is a permanent procedure. Have you informed your partner about it? Have you completed your family? If asked for reversal later – NHS will not pay it. Explain procedure.

TOTAL HIP REPLACEMENT Explain: Duration of procedure: Couple of hours. Life – 6-12 weeks Sex – 6 weeks Driving – 6 weeks DVLA Complications: DVT clouts – presentation : blood thinner medications 3-6 months: Warfarin. Precautions: After surgery: Start exercise suited physiotherapy. Mobilize: Within 24 hours otherwise your joints will stuck, we have to other operation to revisit. After 3 months: Return fully to normal activities. Occupational therapist: Necessary arrangements. Social Workers: Fund. Follow-up: 3-12 weeks. Websites, leafltets. 10-15 years: Total hip & Knee: Differ: THR in front of knee. THK: No squatting movement.