Medical history and reconciliation
Record diagnoses, current medicines, allergies, previous anaesthetic issues and functional status; check uncertain details before intervention.
Understand
A medical history is a clinical risk assessment, not a checklist. Diagnoses, treatments, allergies, previous complications and functional status can matter more than a single label.
Assess
Reconcile drugs including OTC and supplements, clarify indication and timing, and ask about hospital care or recent changes. Record what is uncertain and where confirmation was obtained.
Apply
Adapt the procedure, timing, monitoring or referral to the actual risk. Do not copy an old history forward without checking it with the patient.
Key distinctions
A condition label may conceal very different severity. “Kidney disease” might range from mild stable impairment to dialysis; “heart disease” might be stable or actively symptomatic. Ask what treatment the patient receives and how the condition affects daily function. A current medicines list can reveal risk but should never replace a direct conversation about changes and adverse events.
Think through a case
A patient says they take “a blood thinner” but does not know which one or why. Clarifying the drug and indication changes the surgical and haemostatic plan.
The distinction to remember
Do not infer safety from a medication list copied years ago. Confirm recent changes and relevant allergies at every treatment course.
Test your recall
Why ask who prescribed a medicine and why?
Show answer
The indication may be as important as the drug name for risk assessment.