Sleep, Appetite, Bowel & Bladder Habits in History Taking

• Personal/social history (for baseline habits), or
• History of present illness (when altered by the current disease), or
• Systemic review (as a quick screen of other systems)

How to Ask and What to Record

1. Sleep

• "How is your sleep? Do you sleep well at night?"
• "How many hours do you sleep?"
• "Do you have difficulty falling asleep (initial insomnia), waking up in the middle of the night (middle insomnia), or waking very early (terminal/early morning insomnia)?"
• "Do you feel refreshed after sleep?"
• "Are there any nighttime symptoms - sweating, pain, breathlessness, urge to urinate?"

• Normal: "Sleep is normal/adequate, approximately 6-8 hours, undisturbed."
• Abnormal: Specify the type - insomnia (initial/middle/terminal), hypersomnia, disturbed sleep due to pain/dyspnoea/nocturia/anxiety.

• Early morning awakening - depression, anxiety disorders
• Disturbed sleep due to pain - peptic ulcer (especially night pain), bone metastases, arthritis
• Night sweats + disturbed sleep - tuberculosis, lymphoma, menopause, HIV
• Excessive sleep/hypersomnia - hypothyroidism, severe anaemia, hepatic encephalopathy
• Insomnia - psychiatric illness, hyperthyroidism, steroid use, chronic pain

2. Appetite

• "How is your appetite? Have you noticed any change in your desire to eat?"
• "Are you eating the same amounts as before?"
• "Have you lost any weight recently? If so, how much and over what period?"
• "Do you have any preference or aversion to particular foods?"
• "Does eating make your symptoms better or worse?"

• Normal: "Appetite is normal; no significant change in food intake or body weight."
• Anorexia (decreased appetite): State onset, associated weight loss, food aversions.
• Polyphagia (increased appetite): Note if associated with weight loss (e.g. diabetes, hyperthyroidism) or weight gain (e.g. Cushing's syndrome).

• Anorexia + weight loss - malignancy (especially GI, lung, lymphoma), tuberculosis, chronic liver disease, Addison's disease
• Early satiety - gastric carcinoma ("linitis plastica"), hepatomegaly pressing on stomach
• Aversion to fatty food - gallbladder disease
• Aversion to meat - carcinoma of stomach
• Polyphagia with weight loss - diabetes mellitus, hyperthyroidism, malabsorption
• Bulimia/binge eating - psychiatric disorders

3. Bowel Habits

• "How often do you pass stools? Is this your normal frequency?"
• "Has there been any recent change in your bowel habit?"
• "What is the consistency - hard, soft, loose, watery?"
• "What is the colour of the stools?"
• "Is there any blood or mucus in the stools? Is blood mixed in or coating the outside?"
• "Do you strain to pass stools? Do you feel an incomplete evacuation?"
• "Is there any pain while defecating?"
• "Have you noticed any black or tarry stools (melena)?"

• Normal: "Bowel habit is regular, once daily, well-formed brown stools, no blood or mucus."
• Constipation: Frequency, duration, associated symptoms (straining, bloating, pain).
• Diarrhoea: Frequency per day, consistency, blood/mucus, nocturnal episodes (suggests organic cause).
• Alternating constipation and diarrhoea: Characteristic of irritable bowel syndrome or carcinoma of the colon.

• Fresh blood on the outside of stool - haemorrhoids, anal fissure
• Blood mixed with stool - carcinoma of the colon/rectum, colitis, dysentery
• Black tarry stool (melena) - upper GI bleed (peptic ulcer, oesophageal varices)
• Pale, bulky, greasy, offensive stool (steatorrhoea) - malabsorption (coeliac disease, chronic pancreatitis)
• Pencil-thin stools - carcinoma of the rectum causing partial obstruction
• Alternating habits - colorectal carcinoma, IBS
• Nocturnal diarrhoea - organic disease (IBD, microscopic colitis) rather than functional

4. Bladder Habits (Micturition)

• "How many times do you urinate during the day? And at night (nocturia)?"
• "Is there any difficulty in starting to urinate (hesitancy)?"
• "Is there a poor stream or dribbling at the end?"
• "Do you feel a sense of urgency - that you must urinate immediately?"
• "Is there any involuntary leakage (incontinence)?"
• "Is there any burning or pain while urinating (dysuria)?"
• "What colour is your urine - is it clear, dark, bloody?"
• "Have you noticed any blood in the urine (haematuria) - at the beginning, end, or throughout urination?"
• "Do you feel your bladder is fully emptied after passing urine?"

• Normal: "Micturition is normal, 5-6 times/day, no nocturia, no dysuria, clear yellow urine, no haematuria."
• Abnormal: Document each symptom specifically - frequency, nocturia (number of times), hesitancy, poor stream, terminal dribbling, urgency, urge incontinence, stress incontinence, dysuria, haematuria (timing), colour of urine.

• Frequency + nocturia + poor stream + hesitancy + terminal dribbling - benign prostatic hyperplasia (BPH) in older males
• Dysuria + frequency + offensive urine - urinary tract infection (UTI)
• Painless total haematuria - transitional cell carcinoma of bladder ("first symptom" in carcinoma bladder)
• Initial haematuria - urethral pathology
• Terminal haematuria - vesical neck/trigone pathology
• Total haematuria - carcinoma of bladder, kidney
• Dark yellow/tea-coloured urine - obstructive jaundice
• Stress incontinence - weak pelvic floor (post-partum, post-surgery)
• Urge incontinence - overactive bladder, detrusor instability

How to Write It Up (Model Documentation)

Sleep: The patient sleeps 6-7 hours per night without interruption. No insomnia, night sweats, or early morning awakening.

Appetite: Normal. No significant change in food intake or body weight over the past 3 months.

Bowel habits: Regular, once daily, well-formed brown stools. No blood, mucus, or change in bowel habit.

Bladder habits (Micturition): Normal frequency (5-6 times/day), no nocturia, no dysuria, no haematuria. Clear yellow urine. No hesitancy, urgency, or incontinence.

Bowel habits: The patient has noticed loose watery stools 4-5 times/day for the past 6 weeks, associated with blood and mucus. No nocturnal episodes.

Key Teaching Points

• S Das, A Manual on Clinical Surgery 13th Edition - History-taking chapter (block 1)
• Bailey and Love's Short Practice of Surgery 28th Edition - History taking section