Table of Contents IntroductionPresenting complaintHistory of presenting complaintPast Medical / Surgical HistoryDrug HistoryFamily HistorySocial HistoryOther PointsTry a few questions…Why don’t you try some OSCE stations! Introduction Wash handsIntroduce selfAsk Patient’s name, DOB and what they like to be calledExplain and obtain consent Presenting complaint Determine symptoms which brought patient inStart with an open question History of presenting complaint Explore each symptom (including further symptoms you elicit in system reviews)TimeframeDurationOnset (sudden or gradual)ProgressionTiming (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 operationsAsk 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 diagnosedWhat treatmentControl 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 situationHouse/flat/nursing homeWho’s at homeCarersWho does activities of daily livingMobility aidsOccupation ± occupational history if relevantSmoking 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 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 throughoutAsk ideas and concerns about conditionAsk expectations from consultationConsider the patient’s thoughts and feelingsRemember to pick up on cues throughout historySome 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. Create an account or log in to continue reading. Subscribe Log In 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. Create an account or log in to continue reading. Subscribe Log In What would be in your differential diagnosis for abdominal pain? Ensure you structure your answer. Oops! This section is restricted to members. Create an account or log in to continue reading. Subscribe Log In Why don’t you try some OSCE stations! Chest pain historyHaemoptysis historyChange in bowel habitLeg painAnd there’s lots more here!