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 ± 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…

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!