Splenic Rupture: Medical History

Medical history (history of illness) is an important component in the diagnosis of splenic rupture (splenic laceration).

Family history

Social history

Current medical history/systemic history (somatic and psychological complaints).

  • Can you show me (describe) exactly where the pain is localized?
  • Is the pain always in the same place?
  • How long has the pain been present?
  • Did the pain start slowly or suddenly?
  • If an accident is the cause of the discomfort, give details of how the accident occurred. How did the injuries occur?
    • Blunt trauma:
      • Traffic accident?
      • Sports accident?
      • Accident in the house?
      • Entrapment?
      • Been rolled over?
      • Burial accident?
      • Fall from a greater height
      • Brawl?
      • Abuse?
    • Open trauma
      • Gunshot wound?
      • Stab wound?
      • Impalement injury?
  • Is the pain sharp, pressing, burning, dull?
  • Do you have any other complaints?

Vegetative anamnesis including nutritional anamnesis.

  • When was the last time you ate something?
  • Do you smoke? If so, how many cigarettes, cigars or pipes per day?
  • Do you drink alcohol? If yes, what drink(s) and how many glasses per day?
  • Do you use drugs? If yes, what drugs and how often per day or per week?

Self history incl. medication history.