Share your insights

Help us by sharing what content you've recieved in your exams


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)
    • Symptom-specific questions, e.g. SOCRATES for pain (see exploring symptoms)
  • 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 Β± 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) Γ— years smoked

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…

A 34 year old female patient presents with abdominal pain. How would you explore the history of the presenting complaint?

Oops! This section is restricted to members. Click here to signup!

Once you have explored the symptom, you should undertake a relevant systems review. Which questions would you ask?

Oops! This section is restricted to members. Click here to signup!

What would be in your differential diagnosis for abdominal pain? Ensure you structure your answer.

Oops! This section is restricted to members. Click here to signup!

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!

5 Comments

  1. ASHAD PATTOLA ABDULAZEEZ says:

    Highly informative

  2. Deng Manyuon Mabok says:

    very interested

  3. Kumi Asum Clinton says:

    Would like to learn more on this site

  4. muhammed-ali noor says:

    PC, HPC, PDFS (LOST)
    DOPTA
    SOCRATES
    ICE
    ROS

    1. Samuel says:

      Thank you so much for your response. Just as a gentle reminder, the comments shared here are viewable by all our users. May we kindly confirm if you intended to post this particular comment?

Leave a Reply