Taking a History
For more guides to clinical skills, communication with patients, and procedures, check out the huge OSCE category!
Taking a history is the most basic component of medical examination. Building a rapport early on and asking questions effectively can avoid the need for invasive or unneccessary tests down the line.
- Wash hands, good afternoon, introduction.
- May I confirm your name and date of birth please?
Structure of the interview
- Presenting Complaint
- History of Presenting Complaint
- Past Medical History
- Social History
- Family History
- Systemic Review
- Ideas, Concerns and Expectations
- Summarise information and signpost your next questions
This acronym is especially useful for pain, but can be used for a wide range of symptoms e.g. nausea, tremor, weakness.
- Associated Symptoms
- Time Course (ie worse in morning/evening)
- Exacerbating/Relieving factors
- Severity-1 to 10, 1 being a pinch, 10 being the worst pain imaginable
Open the consultation with an open question such as "How can I help you?" "How are you today?". Alternatively, ask an open question within a specific remit, e.g. "How is your cough today?"
Past Medical History
If you're stuck, check whether the patient is at risk of DEATH:
- Can you tell me what medication you're on please? Any over the counter drugs? Herbal remedies?
- Any medical conditions that run in the family?
- Parents still alive? Cause of death?
- Health of brothers/sisters?
- Smoke? For how long? How many a day?
- Drink? How many pints per day? How long does a bottle last?
- What do you work as? Does your job affect the symptoms/ vice-versa.
Check the systems:
These are the Ideas, Concerns and Expectations of the patient regarding the symptoms, and are really useful for finding out the more emotional aspect of a diagnosis- ‘this pain started when my mother died’. Remember to respond to ICE in the correct way- there’s a mark for this- just be compassionate and empathetic- “I can see that would be upsetting for you”.
- So tell me, what are your ideas about what might be causing this pain?
- Is there anything you’re worried about with this?
- And what are you hoping to get from today's consultation?’’ (be careful with your voice here, can seem confrontational/defeatist)
Summarise at the end
Glossary of useful questions
- Can you tell me about the pain?
- Can you remember when the pain started?
- And how long did it last?
- Can you tell me where the pain is?
- Does it spread to anywhere else?
- Can you describe the nature of the pain?
- Burning, Stabbing, Electric, Dull
- Ever had it before?
- Anything that gives you relief?
- Anything that makes the pain worse
- Any other symptoms associated with the pain?