History & Physical Requirements

You will be expected to perform one complete history and physical. This must be done on a patient seen in the clinic, outpatient or inpatient setting with your mentor. H&P’s do not have to be done only on patients that you participate in their surgery. You are responsible to submit a copy of the completed H&P to your mentor and nurse instructor. These should be mailed to your mentor using interdepartmental mail and a blue evaluation form should be attached. You can hand deliver the copy for the nurse instructor.
Guidelines for a Surgical History and Physical Background:
The major purpose of the history and physical for the surgical patient is to communicate all of that information relevant to the problem that has caused the patient to seek surgical care. Additionally, the surgeon seeks to discover and document all of those conditions that will impact perioperative care.

HISTORY:

Chief Complaint: The signs and/or symptoms that have caused the patient to seek surgical care in the patient’s own words. History of Present Illness: A narrative description of the unfolding of the patient’s story. The events should be arranged chronologically and all relevant positive and negative elements should be included.

Past Medical History:

1. A list of all major medical conditions and events (E.g., prior surgery, hospitalizations, etc.) with dates. 2. Current medications with doses.
3. Allergies with specific reactions.

Social History:

1. Description of life circumstances (E.g., employment, etc.).
2. Description of significant relationships (E.g., spouse).
3. Description of habits (E.g., smoking).

Family History:

1. List of primary family members, age at time of death and cause of death.
2. List other significant illnesses in family.
3. Description of difficulties of family members with anesthesia.

Review of Symptoms:

1. List of relevant positive and negative complaints unrelated to those outlined in HPI. Include any difficulties with anesthesia.

PHYSICAL EXAMINATION:

(Note: The physical exam should include all major organ systems with a detailed examination of the systems requiring surgical intervention) (The following is a general framework with special notation in areas frequently overlooked).
General: Description of patient’s general condition.
Vital Signs:
HEENT:
Mouth: (status of dentition)
Neck:
Chest:
Breast:
CV: Includes a detailed examination of those patients presenting with cardiac or peripheral vascular problems.
Abdomen:
Rectal: If deferred, state the reason why.
GU: Neurologic: Includes general mental status and specific relevant neurological examination. Extremities:

LABORATORY: Include the relevant normal and abnormal values.
RADIOLOGY: Include relevant results.
IMPRESSION: This should be a complete list of the patient’s problems with that problem requiring surgical attention being listed first. It may be appropriate to list a differential diagnosis (E.g., for an abdominal mass) if the exact nature of the problem is not known.
PLAN: This should include a discussion of alternative therapies (non-surgical as well as alternative surgical therapies). The rationale for the selected therapy should be outlined along with a more developed discussion of the risks and benefits of this specific surgical therapy. Finally, you should describe the post-surgical follow-up plan. This would include patient instructions at the conclusion of the specific surgical intervention (E.g., limitations in activity) and further therapy for this condition (E.g., Chemotherapy, further surgery).