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The Medical History

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)
  • 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

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Units of alcohol by alcoholic drink type

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…

Why don’t you try some OSCE stations!

  1. Chest pain history
  2. Haemoptysis history
  3. Change in bowel habit
  4. Leg pain
  5. And there’s lots more here!
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