Basic history

The art of medicine is to determine why a patient has sought help.

The key skills to help establish the underlying cause of a patients' symptoms (the diagnosis) is based on talking to the patient (the history), examining the patient (the examination) and requesting tests like bloods and x-rays (the investigations).

The information gathered from the history and examination is used to form a hypothesis of the possible underlying diagnosis. Investigations can then be used to either confirm or refute this diagnosis. Some diagnoses can be made just by talking to a patient, while others are reliant on a specific test.

As a medical student, student nurse, physician associate, or allied health professional you learn the art of taking a formal history, examining a patient, and interpreting investigations. The history is considered the most important aspect of the interaction between patient and doctor. It is the cornerstone of the doctor-patient relationship and relies on good communication skills. Most information about a patient can be determined by the history alone.

Here, we describe the basic structure to history taking in medicine that is used by all clinicians to gain information from a patient about their condition.

Taking a history from a patient (i.e. talking to the patient about their medical complaint and past medical problems) is an essential skill for all clinicians.

The history has a well-formulated structure to help determine the patient's problems in a logical order and to establish any other relevant information (i.e. previous medical problems, medications). It also helps to sign-post key parts of the history and provides sub-headings when presenting information to another medical professional (another core component of medical practice).

The basic structure of the history is as follows:

• Presenting complaint (PC)
• History of presenting complaint (HPC)
• Past medical history (PMHx)
• Drug history (DHx)
• Family history (FHx)
• Social history (SHx)
• Systems review (SR)
• Ideas, concerns, expectations (ICE)

The PC should be a single sentence that describes the reason why a patient has sought help.

An example of a typical PC would be abdominal pain or headache. 

The PC should capture key information about the patient that helps to focus the history including age, sex and timing of the complaint. This information helps to focus the potential list of causes. For example;

“88 year old female presenting with a 1 month history of abdominal pain”

“23 year old male student presenting with a 12 hour history of headache and fever”

“56 year old male heavy smoker presenting with a single episode of coughing up blood (haemoptysis)”

The HPC is the key part of the history of which the clinician should spend most of their time determining the nature of the complaint.

You should ask a series of both open and closed questions to further clarify the problems being faced by the patient. Key questions may include:

“Could you tell me more about this symptom?”

“How long has the symptom been affecting you?”

“What makes the symptom worse?”

“Is it associated with any other symptoms?”

In general, the HPC can be targeted depending on the presenting problem. You always need to determine the chronicity and associated features of any problem. If it is pain, you need to take a pain history. If the problem is related to a particular system (i.e. heart or lung), you need to ask system-specific questions.

Duration of symptoms

It is essential to determine when the problem started, how long it has been going on for, whether it is constant or fleeting, and whether it has been worsening or getting better.

Associated symptoms

Always ask about associated symptoms such as nausea and vomiting, breathlessness, or fever. As you learn more about clinical medicine you will learn what the important questions are to ask.

Pain history (SOCRATES)

Pain is an extremely common symptom, and it is essential that all clinicians can take a good pain history from a patient. The key parts to a pain history can be remembered by the mnemonic SOCRATES.

• S - Site of pain
• O - Onset of pain (e.g. sudden, gradual)
• C - Character of pain (e.g. sharp, dull, cramping)
• R - Radiation (e.g. spreads from one site to another)
• A - Associated symptoms (e.g. breathlessness, nausea, vomiting)
• T - Timing (e.g. seconds, days, weeks)
• E - Exaggerating & relieving factors (e.g. worse on lying down)
• S - Severity (e.g. on scale of 1 - 10)

System-specific questions

These are groups of questions that should be asked when a patient presents with a particular complaint. They can be grouped based on organ systems (e.g. cardiovascular, respiratory). These are discussed more in our other clinical history notes.

The past medical history is used to determine any previous medical or surgical problems that the patient has had within their lifetime.

It is important to determine each problem, when it started, the treatment required and whether there is any ongoing follow-up. Two examples are shown below:

Myocardial infarction (heart attack):

1. Diagnosed in 2006
2. Underwent percutaneous coronary intervention
3. Had two stents placed
4. Seen in cardiology clinic yearly

Gallstones:

1. Diagnosed in 2004
2. Underwent a cholecystectomy (gallbladder removal) in 2005
3. No further issues

It is often useful to ask the patient specifically about a number of common conditions using the mnemonic MJTHREADS:

• M - Myocardial infarction
• J - Jaundice & liver disease
• T - TB
• H - High blood pressure
• R - Rheumatology (i.e. skin or joint problems)
• E - Epilepsy or seizures
• A - Asthma or other lung conditions
• D - Diabetes
• S - Stroke or TIA

The medication history is used to establish what the patient is taking including both prescribed and over-the-counter (i.e non-prescribed) medications.

For all medications you need to establish the name, dose (i.e. mg/mls/mcg), frequency (i.e. once a day, once a week), and route (oral, intramuscular, intravenous).

The four things to ask about:

1. Prescribed medications
2. Over-the-counter medications
3. Herbal remedies
4. Recreational drugs (i.e. cocaine, ecstasy)

Always establish concordance (i.e. is the patient actually taking their medications), any side-effects and any recent changes (e.g. medications that have stopped or been started or dosing changes).

Taking a family history is essential to determine illnesses that run within the family or may be inherited.

When gathering a family history, you need to find out the condition affected by the relative, the age at which it was diagnosed and the relationship to the patient. A family tree can be used to help represent this information.

Examples:

1. Mother (first-degree relative), lung cancer, diagnosed at 45
2. Maternal aunt (second-degree relative), breast cancer, diagnosed 32 
3. Father (first-degree relative), hypertension, diagnosed 65

The social history is one of the most important components of the medical history.

The purpose of a social history is two-fold. First, you need to find out relevant information about home and domestic activity, job and financial security, travel, smoking and alcohol consumption. Second, you need to consider the effects of their medical conditions on these social issues (i.e. poor mobility due to heart failure, need carers due to dementia).

The key parts of the social history can be remembered using the mnemonic LOLAS DIET:

• L - life- who does the patient live with?
• O - occupation
• L - living - activities of daily living
• A - alcohol consumption
• S - smoking history
• Di - diet
• E - exercise
• T - travel

Activities of daily living (ADL)

This refers to what the patient can do for themselves and how any illnesses may be affecting them. It is important to determine information such as whether they can wash and dress, can they go to the bathroom by themselves, do they have any carers, do they walk with any sticks or frames.

In older patients, the Rockwood Clinical Frailty Scale should also be used to determine how 'frail' a patient is based on their ability to complete personal or domestic tasks. This is based on a patients' capability two weeks ago and may need discussion with the next of kin or carer. The clinical frailty score is a reliable predictor of outcomes in patients' presenting through emergency services. The scale runs from 1 (very fit) to 9 (terminally ill).

Alcohol consumption

This needs to be quantified based on a weekly average of alcohol intake. The national advice for both men and women is to not drink more than 14 units/week on a regular basis, with several alcohol-free days and a max of 3-4 units in any one day.

Screening alcohol dependence

Alcohol abuse and dependency are major issues. A variety of questionnaires are available to screen for the risk of harmful alcohol use. This has two major benefits:

1. Identify patients at risk of alcohol-related morbidity (to provide intervention, including the offer of referral to alcohol services)
2. Identify patients at risk of alcohol withdrawal in the inpatient setting

Two commonly used tools are:

• CAGE
• AUDIT

CAGE is a series of 4 screening questions that are used to determine the risk of excessive drinking or alcoholism. Each question equals 1 point.

• Have you ever felt you needed to Cut down on your drinking?
• Have people Annoyed you by criticising your drinking?
• Have you ever felt Guilty about drinking?
• Have you ever felt you needed a drink first thing in the morning (Eye-opener) to steady your nerves or to get rid of a hangover?

A score of ≥2 should warrant further assessment for alcohol dependence. In the inpatient setting, this would warrant assessment for alcohol withdrawal

AUDIT is a more detailed questionnaire that was developed by the World Health Organisation (WHO). It consists of 10 questions with a score of 0-4 per question. It should start by saying 'Now I am going to ask you some questions about your use of alcoholic drinks during this past year' that is followed by each question as written. A score ≥8 is an indicator for harmful alcohol use.

Smoking history

Smoking history is described in the number of pack years.

A single pack-year is equivalent to smoking 20 cigarettes a day for a whole year. Therefore, if someone has smoked 20 cigarettes a day for 40 years, they have a 40 pack-year smoking history.

This can be explained by the following formula:

Pack years = (Cigarettes smoked per day / 20) x Number of years

The systems enquiry is a way of screening for any other symptoms related to major systems within the body. 

The systems review can be completed at any point during the consultation but is usually completed at the end or following the history of presenting complaint. It is important to ask brief, closed questions, to ensure you cover the major symptoms in a timely fashion. However, a positive response should be further investigated fully like in the history of presenting complaint. 

The best way to approach the systems review is to start by asking four general questions, and then ask short closed questions from head-to-toe. The four general questions are useful to screen for malignancy or chronic infections.

The four general questions include:

1. Weight loss - Have you had any significant weight loss?
2. Fever - Have you had any fevers or night sweats?
3. Energy - Have you had a reduction in your energy levels?
4. Appetite - Has your appetite changed?

The short, closed questions, from head-to-toe may be as follows:

• Headaches
• Visual changes
• Hearing problems
• Swallowing problems
• Chest pain
• Shortness of breath
• Abdominal pain
• Urinary symptoms
• Bowel symptoms
• Skin rashes
• Joint pain

At the end of every consultation, you must enquire as to the ideas, concerns and expectations of the patient that can be shortened to the mnemonic 'ICE'.

Ideas

‘Do you have any idea about what could be going on?’

Ideas refers to the patients' own thoughts about what the problem could be and helps to guide your own diagnostic process.

Concerns

‘Is there anything which is concerning you at the moment?’

It is good practice to address any concerns a patient has during the consultation. It also helps to provide reassurance and offers time for the patient to ask any questions they might have.

Expectations

‘Was there anything you were hoping for from our discussion today?'

It is important to establish the patients' expectations during or at the end of the consultation. For example, a patient presenting with a viral illness may be expecting to get antibiotics.

Last updated: September 2021