Hx Taking Surgery Guidelines Ver. 4

DDx = Trauma # Infection # Neoplasm # Congenital # Autoimmune # Metabolism # Blood # Endocrine # Drugs

* Please add on if theres anything missing and improve this guideline

PERSONAL DATA1. Bed + MRN2. Full Name3. Gender & Race4. DOB5. Ht/Wt/BMI6. Date/Time Admit7. Date/Time Clerk8. Husband/Wife

(Name/Age/Occp)9. Total Income10. Address/House Type

PCs & HPCs

Pain1. Site2. Onset3. Characteristic

(burn,throb,stab,constrict,colicky,aching)

4. Radiation5. Associated Sympt6. Time/Duration7. Exacerbating/Relieving8. Severity/Score 9. Progression/Ending

Lumps/Ulcer1. When & how noticed?2. Changes/Development3. Symptoms4. At other sites on the

body?5. Idea what cause it?

Fever1. Type (Cont./Remit/

Intmint./Relapse)2. Character3. Duration

(sudden/gradual)4. Nocturnal Variation5. Chills/Rigor?6. Rashes/Joint Pain7. Frequency/Recurrent8. Temperature9. Medication10. Hx Contact11. Hx Travel12. Fits

Vomitting1. Frequency2. Characteristics3. Volume4. Projectile/NonProjctle5. Hematemesis (colour)6. Duration7. Exacerbating/Relieving8. Timing9. Nausea

Diarrhea1. Character/Consistency2. Colour3. Frequency4. Amount5. Blood/Mucous6. Pain7. Abd. Distension8. Flutulance

Constipation1. Onset2. Time3. Bleeding4. Straining/Prolapse5. Tenesmus

Loss of Weight1. How much?2. Period of time?3. Diet (type & intake)

Cough1. Duration2. Sound3. SOB?4. Cyanosis5. Type (Productive?)6. Sputum Character7. PostTussive (Condition)8. Runny nose9. Frequency10. Exacerbating/Relieving11. Medication

SYSTEMIC REVIEWRESPI- runny nose, cough, wheeze, SOB, activity limitationENT– throat infections, snoring, noisy breathingCVS- sweating, cyanosis, pallor, SOB, exercise tolerance, murmurGIT - appetite, diet, vomiting, pain, abdominal distention, bowel habit, stools,MSK - gait, limb pain, joint pain @ swelling,CNS - headaches, fits, hearing, visionGnUr - pain, colour, frequency, trainingH&L - anemia, bleeding tendency or clotting tendency.

Systemic Review Gynae1. Menstrual Hx

a. LMPb. Lenght/Delayc. Volumed. 1st Period (Age)e. Irregular bleed?

2. Dischargea. Colourb. Amount (# pads)c. Durationd. Pain/Itch/Rash

3. Obstetrica. # of pregnancy b. # of miscarriagesc. Complications?

4. Contraceptiona. Type/Nameb. For how long?

5. Menopausea. Whenb. Bleeding?c. HRT?

Family Hx1. Parents2. Siblings3. Partner (if releveant)

Social Hx1. Smoking/Drink/Drugs2. Diet3. Occupation4. Income5. Education6. House type &

environment

PCs & HPCs (Cont.)Hernia

1. Location2. Direct/Indirect?3. Simple / Obstructed /

Strangulate?4. Complete/ Incomplete

(What level?)5. Reducible ?6. Assoc. Symptom7. Hx of straining (heavy

lifting, cough, constipation, micturation problems)

PAST Med Hx6. Pass Illnesses7. Hospitalizations8. Surgery9. Medications10. Allergies

Name & RN:Full Blood Count

WCC (x10/L) 4-11Hb (g/dL) ♂13-18/♀11.5-16Neuto (%) 40-75Lymph (%) 20-45Eosino (%) 1-6Platlet (x10/L) 150-400

Renal ProfileUrea (mmol/L) 2.5-6.7Na (mmol/L) 135-145K (mmol/L) 3.5-5Crtinn (µmol/L) 70-150

Liver Function TestProtein (g/L) 60-80Albumin (g/L) 35-50Ttl.Bilrb (µmol/L) 3-17Direct (µmol/L) < 7 µmol/LIndirect (µmol/L) < 12 µmol/LALP (U/L) 30-150ALT (U/L) 5-35

Coagulation ProfilePT (sec) 12-14INR (sec) 0.8-1.2APTT (sec) 26.0-33.5

Serum ElectrolyteMg (mmol/L) 0.75-1.05PO4 (mmol/L) 0.13- 0.22Ca (mmol/L) 2.12-2.65

Cardiac EnzymesCK/CK-MB (U/L) 25-195AST (U/L) 5-35LDH(U/L) 70-250

OthersESR ♂10/♀15CRP (mg/dL) < 10Lactate 0.6-2.4 (V)/-1.8 (A)AmmoniaD-dimer (mg/L) < 0.5

Infective ScreeningHIVHBsAgHep C Ab

Culture & SensitivityBloodUrineTissueFluidPus

Arterial Blood GaspH 7.35-7.45PO2 (mmHg) 75-100 mmHgPCO2 (mmHg) 35-45 BE (mmol/L) 2HCO3

Spo2

Name & RN:Lipid Profile

Ttl Chol (mmol/L) < 5.0HDL (mmol/L) 0.9-1.93LDL (mmol/L) <2.0TG (mmol/L) 0.55-1.9

X-Ray

USS

Other Investigations