Taking a history
The basics (1)
The basics (1)
This section will not go over the basic structure of the medical interview. Instead, it will focus on the basics that must be asked when you are clerking a patient requiring hand/plastic surgery services.
These are important things to ask and note down:
- Age, Handedness
- Mechanism of injury, time of injury, first aid/initial management
- If amputation: Time of amputation, warm ischemic time, cold ischemic time (if stored)
- Past medical/surgical history (esp. diabetes)
- Drug history (especially anticoagulants), tetanus immunization status
- Allergies (especially antibiotics)
- Social history: Occupation, Smoking status, EtOH, Sports
- Mobility and home situation (support, carers?) if elderly or anticipated self-care issues
- Telephone contact details
Below is an adaptation of a clerking proforma included in the Green's Operative Hand Surgery Textbook which can be used as a guide (2):
Clerking template adapted from the Green's Operative Hand Surgery 6th Edition by Wolfe, Hotckiss, Pederson and Kozin (2011).
References
References
1. Chiu TW. Stone’s Plastic Surgery Facts: A Revision Guide, Fourth Edition. CRC Press; 2018. 2. Green DP, Wolfe SW. Green’s operative hand surgery. Elsevier/Churchill Livingstone; 2011.
Image references:Header image - Licensed with Adobe Stock (2019)
Image references:Header image - Licensed with Adobe Stock (2019)
This subpage has been reviewed by:
1) Mr. Martin Shapev - Plastic Surgery Registrar, RD&E (06/02/2020)
1) Mr. Martin Shapev - Plastic Surgery Registrar, RD&E (06/02/2020)