Taking a history: Conclusion and closure
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.
Questions that can be asked include:
You will often have to use a variety of questions to prompt the patient as:
The medical history is useful as it determines:
It is logical to ask about allergies after the treatments history. This includes:
You should try to determine what happened in order to differentiate between an allergy and a side effect.
Again, you need to be specific about this area:
You also need to ask if the parents are alive and, if not, at what age they died and the cause of death.
Questions about the family history should be obtained sensitively as they may bring back distressing memories for the patient. You should develop your own method of putting the patient at ease. One method