History of presenting complaint

The chronology of the illness must be determined.

This may be achieved by asking:- "how and when began" or: "when first noticed anything wrong" or: "when last well"

This should begin by stating when the patient was last perfectly well. Symptoms should then be described in chronological order of onset. Both the actual date of onset and the length of time prior to admission should be recorded. The symptoms should never be dated by the day of the week as this later becomes meaningless. There follows a detailed description of each symptom, and for this purpose the patient's own words should be used.

Avoid using technical language when describing a patient's history. Do not say "the patient complained of melaena" rather "the patient complained of passing loose black motions"

Usually all symptoms must be described in detail whether they are apparently relevant or not. When patients are unable to give an adequate or reliable account, the necessary information must be obtained from friends or relations. The source of the information should be stated.