Table of Contents
Introduction
- Wash hands
- Introduce self
- Ask Patient’s name, DOB and what they like to be called
- Explain and obtain consent
Presenting complaint
- Determine symptoms which brought patient in
- Start with an open question
History of presenting complaint
- Explore each symptom (including further symptoms you elicit in system reviews)
- Timeframe
- Duration
- Onset (sudden or gradual)
- Progression
- Timing (intermittent or continuous)
- Symptom-specific questions, e.g. SOCRATES for pain (see exploring symptoms)
- Timeframe
- Relevant system reviews to determine presence/absence of possible associated symptoms (see systems review)
Past Medical / Surgical History
- Ask generally about medical conditions and past operations
- Ask specifically about conditions/risk factors relevant to differentials (e.g. hypertension, diabetes etc. for cardiac chest pain)
- For relevant conditions, find out more information, for example:
- When diagnosed
- What treatment
- Control of condition
Drug History
- Allergies (including reactions)
- Medications (with doses and frequencies) – include over-the-counter medications and natural remedies
Family History
- Ask family history of conditions relevant to differentials
Social History
- Living situation
- House/flat/nursing home
- Who’s at home
- Carers
- Who does activities of daily living
- Mobility aids
- Occupation ± occupational history if relevant
- Smoking and alcohol:
- Smoking (calculate pack years)
- Alcohol (calculate weekly units)
- Recreational drugs (if relevant)
- Travel/pets/hobbies/sexual history if relevant
Pack years = (number of cigarettes smoked per day/20) × years smoked
Other Points
- Ideas, concerns, expectations, feelings: this is a vital part of the history and should be integrated throughout
- Ask ideas and concerns about condition
- Ask expectations from consultation
- Consider the patient’s thoughts and feelings
- Remember to pick up on cues throughout history
- Some specialties have specific histories with additional parts (see specific histories)
- Finish by summarising and ask the patient if they have any questions
Try a few questions…
A 34 year old female patient presents with abdominal pain. How would you explore the history of the presenting complaint?
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Once you have explored the symptom, you should undertake a relevant systems review. Which questions would you ask?
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What would be in your differential diagnosis for abdominal pain? Ensure you structure your answer.
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