Intended for healthcare professionals

Student Education

Taking a history: Conclusion and closure

BMJ 2005; 331 doi: (Published 01 October 2005) Cite this as: BMJ 2005;331:0510358
  1. Nayankumar Shah, senior lecturer in general practice1
  1. 1Newcastle, Australia

In the second part of the series, Nayankumar Shah takes us from medical and surgical history to conclusion and closure

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:

  • Prescribed drugs

  • 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 …

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