History Taking Format

1. Name / Age / Sex / State
2. Chief Complaints
3. H/o Present Illness (History of Present Illness)
   • Duration
   • Episodes
   • Association
4. Past History - DM / HTN (Diabetes Mellitus / Hypertension)
5. Surgical History
6. OBG History - Delivery: LSCS / NVD (Lower Segment Caesarean Section / Normal Vaginal Delivery)
   • Menstrual History
7. Family History
8. Personal History

Detailed Explanation of Each History-Taking Component

1. Name / Age / Sex / State (Patient Identification)

• Name: Knowing the patient by name builds rapport and psychological trust. Calling a patient by name before a procedure or operation reassures them and improves the clinician-patient relationship.
• Age: Age directly correlates with disease probability. Examples:
  • Infants: acute osteomyelitis, Wilms' tumour, intussusception
  • Teenagers: sarcomas
  • 14-25 years (females): appendicitis
  • 40+ years: most carcinomas
  • Elderly: osteoarthritis, benign prostatic hyperplasia
  • Congenital anomalies (e.g., cleft lip, phimosis) present from birth, while others (e.g., branchial cyst, persistent urachus) appear later.
• Sex: Many diseases have sex predilections. Thyroid disease, cystitis, movable kidney and visceroptosis are commoner in females. Carcinomas of the stomach, lungs, and kidneys are commoner in males. Haemophilia exclusively affects males.
• State/Residence & Social Info: Certain diseases have geographical distribution (e.g., filariasis in Orissa, gallbladder disease in West Bengal). Occupation matters too - varicose veins in bus conductors, bladder neoplasms in aniline dye workers, tennis elbow in tennis players. Social status influences disease risk (appendicitis in higher social status; tuberculosis in lower).
• Address is recorded for future correspondence and follow-up.

2. Chief Complaints (C/C)

• Ask: "What are your complaints?" or "What brings you here?"
• Each complaint is listed with its duration (ask: "How long have you been suffering from each of these?")
• If multiple complaints begin simultaneously, list them in order of severity
• The patient should be confirmed to have been well before the stated duration - this prevents missing earlier, related symptoms the patient might consider insignificant (e.g., a patient not mentioning prior "hunger pains" who now presents with peptic perforation)

• Swelling in the neck - 1 year
• Fever (evening) - 10 months
• Pain in swelling - 6 months
• Sinus in the neck - 1 month

3. History of Present Illness (H/o PI)

a) Duration

b) Episodes (Mode of Onset and Progression)

• Was onset sudden or gradual? Was there a precipitating cause?
• Ask: "How did the trouble start?" and "What is the next thing that happened?"
• Never ask leading questions (e.g., "Doesn't the pain go to the right shoulder?") - these generate artificially confirmatory answers. Ask open-ended questions instead (e.g., "Does the pain ever move? Where?")
• Record in the patient's own language, not in medical terms
• Negative history is equally important - e.g., absence of watery discharge during meals in a patient with a cheek sinus rules out a parotid fistula

1. Location
2. Quality
3. Intensity
4. Temporality (onset, duration, frequency)
5. Aggravating factors
6. Alleviating factors
7. Associated/related symptoms

c) Association (Associated Symptoms)

4. Past History (DM / HTN)

• Medical conditions: Diabetes mellitus (DM), hypertension (HTN), asthma, tuberculosis, rheumatic fever, peptic ulcer, acute pancreatitis, gallbladder disease, bleeding disorders
• Surgical history: Previous operations - type and date (listed chronologically)
• Accidents/trauma previously sustained
• Drug history: All current and past medications. Particularly important: steroids, insulin, antihypertensives, diuretics, ergot derivatives, MAO inhibitors, hormone replacement therapy, and contraceptive pills - relevant to anesthesia and drug interactions
• Allergy history: Any drug or dietary allergies. Must be highlighted prominently (in red on the case sheet) - missing this can lead to life-threatening reactions

5. Surgical History

• Type of surgery (e.g., appendicectomy, cholecystectomy, caesarean section)
• Date and indication
• Complications during or after surgery
• Anaesthetic problems encountered
• This is critical as prior surgeries can cause adhesions, alter anatomy, affect the current condition, and influence anesthetic planning

6. OBG History (Obstetric, Gynaecological, and Menstrual)

Obstetric History - Delivery: LSCS / NVD

• G (Gravida): Total number of pregnancies
• P (Para): Number of deliveries (live + stillbirths)
• A (Abortions): Miscarriages or terminations, with dates
• L (Living children)
• Type of delivery: NVD (Normal Vaginal Delivery) or LSCS (Lower Segment Caesarean Section - and the reason for it)
• Any complications during pregnancies or deliveries

Menstrual History

• Is menstruation regular or irregular?
• Duration of each cycle and cycle length (e.g., 5 days/28 days)
• Amount of flow: normal, scanty, or heavy
• Dysmenorrhoea: Is pain associated with menstruation?
• LMP: Last menstrual period (date) - essential to rule out pregnancy
• Any white/vaginal discharge (leucorrhoea)

7. Family History

• Are parents alive? If deceased, what was the cause of death?
• Do any family members have similar complaints?

• Haemophilia (X-linked)
• Tuberculosis (infectious, household contacts)
• Diabetes mellitus and essential hypertension
• Peptic ulcer and piles/fissure-in-ano
• Cancers - especially breast cancer and colorectal cancer (those with a family history have significantly increased risk)
• Psychiatric conditions, asthma, epilepsy

8. Personal History

Summary Table