Surgical Case History: A Detailed Guide

Surgical Case History: A Detailed Guide

A surgical case history is an important document in the process of surgical treatment, helping doctors understand the patient’s condition and develop an effective treatment plan. Surgical case histories are divided into two main types:

1. Pre-operative Case History:

• Order of Steps:

• Administrative: Includes patient’s personal information such as name, age, gender, address, occupation, phone number…

• Reason for Admission: Should be obtained directly from the patient, not relying on information from lower levels of healthcare.

• History of Present Illness: Includes current medical conditions and past illnesses.

• Past History: Divided into four parts: medical, surgical, family, and epidemiological.

• Physical Examination:

• Symptoms: These are symptoms reported by the patient, helping doctors guide the examination.

• General Condition: Includes physical condition, vital signs, and consciousness.

• Signs: These are symptoms observed by the doctor during the examination.

• Note on Abdominal Examination: Observation – Auscultation – Percussion – Palpation.

• Clinical Diagnosis or Differential Diagnosis: Doctors suggest possible diagnoses based on collected information.

• Diagnostic Tests: Doctors order necessary tests to accurately determine the patient’s condition.

• Definitive Diagnosis: After receiving test results, doctors make a definitive diagnosis.

• Treatment Plan: Doctors recommend appropriate treatment for each case.

• Prognosis: Predicting the potential development of the disease. Using the ASA (American Society of Anesthesiologists) scale to assess the patient’s condition before surgery. The ASA scale has 6 levels, from level 1 (healthy patient) to level 6 (brain-dead patient).

• Prevention: Doctors advise patients on how to prevent disease recurrence.

2. Post-operative Case History:

• Differences between Pre-operative and Post-operative: The post-operative case history includes information about the disease progression after surgery.

• Sequence of the Post-operative Case History in the Admission Status Section:

• Signs

• Symptoms

• General Condition

• Clinical Diagnosis

• Diagnostic Tests

• Definitive Diagnosis

• Surgical Indication

• Pre-operative Preparation

• Post-operative Protocol

• Post-operative Medications

Notes on Concepts:

• 7 Attributes of Symptoms: These include location, quality, quantity, timing, onset, factors that increase/decrease symptoms, and associated symptoms. These 7 attributes fall under the History of Present Illness section of the case history.

• PARA: A term in obstetrics, describing a mother’s obstetrical history: number of full-term births, premature births, miscarriages, and living children.

• Physical Examination: Includes signs observed by the doctor during the examination, not symptoms.

Remember, a surgical case history is a very important document in treating patients. Writing a careful, complete, and accurate case history will help doctors make the best treatment decisions for patients.