Taking the patient’s history is a very important part of the examination, and in many cases, a diagnosis can be made from the history alone. All relevant information should be collected and arranged logically so that it clearly describes the development of the illness.

The recorded history should begin from the time the patient first noticed any symptoms, physical changes, or any deviation from normal health. All symptoms and events up to the present time must be included, with dates and times noted as accurately as possible. The patient should be encouraged to speak freely without interruption, but specific guiding questions should also be asked to help clarify details. Questions such as how the illness started, what the first symptom was, how long it has been present, how it affects the patient, and what happened afterward are useful in building a clear picture.

It is important to focus on the main symptoms, such as abdominal pain or severe headache, rather than vague complaints like tiredness or loss of appetite, which are common in many illnesses. The patient should also be asked whether similar symptoms have occurred before, and if so, what diagnosis and treatment were given at that time. Information about current medications must also be obtained, since the present illness may be related to a reaction or allergy to a drug.

Pain

Pain is one of the most common symptoms and should be carefully assessed. The patient should be asked how the pain started and what he was doing at the time. The exact location of the pain should be identified by asking the patient to point to it. The severity of the pain should be assessed, along with its nature, whether it is sharp, dull, cramping, or aching. It should also be determined whether the pain is constant or occurs intermittently. The examiner should ask whether the pain spreads to other areas, whether it has moved from one place to another, and whether anything makes it better or worse. It is also important to know whether medication provides relief.

Past Illnesses

The patient should be asked about any previous illnesses, injuries, or surgeries. This information can help rule out certain conditions or suggest recurrence of a previous disease. For example, if a patient has had an appendix removed, pain in that area is unlikely to be appendicitis. Similarly, if a patient has a history of ulcers and presents with similar symptoms, it may indicate a recurrence. Previous diagnoses such as diabetes or high blood pressure are important, as they may worsen during illness and lead to complications. The patient should also be asked about any known drug allergies or adverse reactions to medications.