Bệnh nhân phải có một lịch sử đầy đủ được thực hiện để thiết lập các vấn đề trong đó bệnh nhân than phiền. Lịch sử quá khứ, xem xét lại hệ thống, và lịch sử gia đình nên bao gồm tất cả các thông tin có thể ảnh hưởng đến các thủ tục phẫu thuật được đề xuất và kết quả của nó chẳng hạn như trước khi phẫu thuật bụng. | Part IV Part IV Preoperative Chapter 16 Preoperative Consultation Melvin A. Shiffman 16 History The patient must have a sufficient history taken to establish the problem of which the patient complains. Past history review of systems and family history should include all information that may impact on the proposed surgical procedure and its outcome such as prior abdominal surgeries. There must be an attempt to rule out cardiac or pulmonary problems allergies bleeding problems diabetes mellitus and other serious medical disorders. Information should be obtained about any medications being taken such as aspirin ibuprophen herbals antihypertensives anticoagulants and estrogens. It is important to elicit prior thrombophlebitis or pulmonary embolus. Family history should include questions about bleeding tendencies or thromboembolism. Physical Examination The physical examination should not be cursory. The systems examined should include the heart and lungs as well as the area s of the body involved in the patient s complaint s . There should be a careful evaluation for possible abdominal wall or umbilical hernias if abdominal liposuction is to be performed. The medical record should contain all of the appropriate information for another physician who may examine the record to come to the same conclusions and to make the same decisions. Preoperative and postoperative photographs are essential. Medical Record The content of the medical record should be sufficient to show that an informed consent has been given through explanation of the proposed procedure possible viable alternatives and the risks and complications. This does not mean only forms signed by the patient containing the information. The physician should state in the record that the discussion took place on the day of the discussion. The patient must make a knowledgeable decision about the proposed procedure and the physician must take an active part in making sure this is achieved even if some .
