Taking a history: Conclusion and closureBMJ 2005; 331 doi: https://doi.org/10.1136/sbmj.0510358 (Published 01 October 2005) Cite this as: BMJ 2005;331:0510358
- Nayankumar Shah, senior lecturer in general practice1
- 1Newcastle, Australia
Following the first part of the series on history taking, which considered introduction and the presenting complaint, we move on to medical and surgical history.
Medical and surgical history
Questions that can be asked include:
“Have you had any serious illnesses?”
“Have you ever been admitted to hospital?”
“Have you had any operations?”
You will often have to use a variety of questions to prompt the patient as:
He or she may have forgotten the incident
He or she may not consider such an episode important (or relevant) to the current problem.
The medical history is useful as it determines:
Whether the patient has had this problem before
What investigations were carried out and what diagnosis was made at that time.
What other problems the patient has
The patient's understanding of his or her illness.
Treatment and other drug history
This should include:
Over the counter treatments-that is, drugs bought without a prescription
Herbal or “natural” treatment
Illegal or “recreational drugs.”
Patients are often unsure of the drugs they are taking. Under these circumstances, it is worthwhile using the medical history and asking if they are on any treatment for each problem: “Do you take anything for your arthritis?” and so on.
Alternatively, if the patient knows the treatments, it is helpful to ask him or her what they are for-sometimes this gives additional information as to the patient's illnesses. For instance, the patient may have forgotten to tell you that he or she has hypertension, and this is discovered only from the treatment and other drug history.
Over the counter drugs
Many drugs can be obtained without prescription, so it is essential to ask about over the counter drugs:
They may be vital-for example, the patient who takes aspirin for …