General History taking for surgical outpatient clinics

Hello Mr. …. Please have a seat. I am …(position)…
Personal history
Check Full Name – Date of Birth – Occupation (if appropriate)

Surgical Complaint
Pain – Swelling – Dysfunction – Others

What is the problem? / How can I help ? / I have received letter from your GP saying that….
Tell me more about that.
Tell me more about …. What about ….? Do you have ….?

History of present complaint (analyse this symptom appropriately by asking more questions)

Other symptoms in relation to the main complaint

Main general surgery Systems (for Related symptoms press the links):
Chronic limb ischemia
Varicose veins
Lymphatic disorders
The Mouth and the tongue
Salivary glands
The neck
Thyroid gland
Breast
Abdominal wall and hernia
Scrotum
Abdomen (GIT)
Rectum and anal canal
Kidney and the urinary tract

History of present investigations and treatment
Have you had any scans or blood tests for this?

Systematic direct questions
I’m now going to ask you a series of questions about common medical problems.
This to make sure we do not mess anything that may be important.
CVS
Do you have any trouble with your heart, chest pain or palpitation?
Respiratory
Do you have any trouble with your lungs, shortness of breath, coughing or sputum?
GIT
Do you have problem in digestion, lose weight, difficulty in swallowing, heart burn, nausea/vomiting, abdominal pain, swelling, change of bowel habits, rectal bleeding?
Genitourinary
Do you have any problems passing urine, change of color, pain, smell?
Diabetes Mellitus
Female in child bearing period
Do you have problems in your periods?

Past history
Have you been admitted to a hospital before?
Have you had any operations before?
Do you take any regular tablets / medications? Any blood thinners?
Do you have any allergies?

Family history
Do you have any similar problem or specific conditions in your family (children, parents, brothers, sisters)?
Social history
Do you smoke? That do you smoke? How much? For how long?
Do you drink? How much/week?

Patient concern
Do you have any specific concerns?

Summery
To summarize …. (repeat positive findings to the patient)
The plan will be (usually to perform physical examination first and discuss if you need more investigations, consultations like MDT and discuss possible treatment options)