history taking

Reading File

Asking for Preferences

Finding Sources

Reading File

I now have a solid base from the textbooks. Here is the complete, structured overview of history taking:

History Taking - Complete Structured Overview

A complete clinical history follows a standard sequence, moving from patient identification through to family background.

1. Patient Particulars (Biographical Data)

Always record these before eliciting complaints. Each item has diagnostic significance:

Particular	Clinical Relevance
Name	Builds rapport; prevents mix-ups
Age	Congenital anomalies (birth/infancy), sarcomas (teens), appendicitis (14-25 y), carcinomas (>40 y), BPH/OA (elderly)
Sex	Thyroid disease, cystitis - commoner in females; GI/lung/renal cancers - commoner in males; haemophilia - males only
Religion	e.g. carcinoma of penis rare in Jews/Muslims (circumcision); intussusception risk after Ramadan fast
Social status	Appendicitis - higher social class; TB - lower social class/poor nutrition
Occupation	Varicose veins (bus conductors), bladder cancer (aniline dye workers), scrotal cancer (chimney sweepers), tennis elbow (tennis players)
Residence	Filariasis (endemic areas), gallbladder disease (geographical variation)
Full address	For correspondence and follow-up

Ask: "What are your complaints?" or "What brings you here?"
Record all complaints in chronological order of appearance
Note the duration of each complaint
If multiple complaints start simultaneously, list in order of severity
Confirm: "Were you perfectly well before this started?" - ensures no hidden earlier symptoms are missed

Example format:

Covers from onset of first symptom to the time of examination. Three parts:

Mode of onset - sudden vs. gradual; precipitating cause if any
- Ask: "How did the trouble start?"
Progress / evolution of symptoms - chronological sequence
- Ask: "What happened next?"
Treatment received - type of treatment, doctors seen, medications taken

Key principles:

Record in the patient's own words, not medical jargon
Let the patient narrate freely; redirect if they wander
Avoid leading questions (e.g. don't ask "Does the pain go to the right scapula?" - patient will likely say yes to please you; instead ask "Where does the pain go?")
Never ask "What are you suffering from?" - you'll get a diagnosis, not a history

For pain (SOCRATES mnemonic):

Previous illnesses, hospitalisations, and surgical history
Previous anaesthetic events (difficult airway, suxamethonium apnoea, intra-abdominal adhesions)
Important negatives should be documented (e.g. "no diabetes, no hypertension")

Key conditions to screen:

All current medications (prescription, OTC, herbal, supplements)
Dosage and duration
Allergies - document the drug AND the type of reaction (rash, anaphylaxis, GI intolerance)
Recreational drug use and alcohol consumption (associated with adverse surgical outcomes)

Many diseases have a familial tendency. Always enquire about:

Parents (alive? health? cause of death?)
Siblings and children
Specific conditions: haemophilia, TB, diabetes, hypertension, peptic ulcer, most cancers (especially breast cancer), fissure-in-ano, piles

Smoking - type (cigarettes/cigar/pipe), frequency, pack-years
Alcohol - quality and quantity
Diet - regular/irregular, vegetarian/non-vegetarian, spicy food
Marital status
Mobility and ability to communicate (important for surgical planning, discharge, rehabilitation)

In women - menstrual history (MUST record):

Record vaccination status for:

Letter	Component
P	Patient particulars
C	Chief complaints
H	History of present illness
P	Past medical/surgical history
D	Drug history & allergies
F	Family history
I	Immunization (paediatric)
+	Personal & social history

Sources: S Das - A Manual on Clinical Surgery, 13th Ed. | Bailey and Love's Short Practice of Surgery, 28th Ed.

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