Taking a history from a patient is a fundamental skill for medical students during examinations and for doctors throughout their careers, regardless of their specialty. This process evaluates both your ability to communicate effectively and your understanding of the necessary information to gather. While the precise questions may differ based on the type of history needed, following a standard structure like the one outlined below is beneficial for practicing and presenting patient histories.

In certain situations, it may be necessary to obtain information from someone accompanying the patient, such as a family member, friend, or caregiver. This is often the case with children or adults whose mental state prevents them from providing a clear history themselves.

Procedure Steps

Step 01
Begin by stating your name, confirming the patient’s identity, and asking for their consent to speak with them. If you plan to write notes during the conversation, ask for their permission beforehand.

Step 02 – Presenting Complaint (PC)
Identify the main issue or symptom the patient reports, such as chest discomfort.

Step 03 – History of Presenting Complaint (HPC)
Gather detailed information about the primary issue.
Using chest discomfort as an illustration, inquire about:

• Site: The precise location of the discomfort?

• Onset: When it began, whether it’s constant or intermittent, and if it started suddenly or gradually?

• Character: How the discomfort feels (e.g., sharp, burning, squeezing)?

• Radiation: If it spreads or moves to another area?

• Associations: Any other symptoms occurring with the discomfort (e.g., perspiration, nausea)?

• Time course: If it follows a pattern or how long episodes last?

• Exacerbating / relieving factors: What makes it better or worse?

• Severity: How intense the discomfort is, perhaps using a 1-10 scale?

The SOCRATES mnemonic is useful for pain assessment.

Step 04 – Past Medical History (PMH)
Collect information about any other health conditions the patient has had.

Step 05 – Drug History (DH)
Determine which medications the patient is currently taking, including the dose and frequency (e.g., daily, twice daily). Also, ask about any drug allergies.

Step 06 – Family History (FH)
Obtain relevant information about health conditions in the patient’s family, such as diabetes or heart disease. Inquire about any inherited conditions like polycystic kidney disease.

Step 07 – Social History (SH)
Learn about the patient’s lifestyle and background. Be sure to ask about smoking and alcohol use. Depending on the presenting complaint, questions about driving might be relevant (e.g., driving restrictions after a heart attack). Inquire about the use of recreational substances like cannabis or cocaine. Understand who lives with the patient; they may be a caregiver, which affects planning if they need hospital admission.

Step 08 – Review of Systems (ROS)
Briefly explore the status of other major body systems not directly related to the presenting complaint. If the main issue involves the cardiovascular system, focus on others.

Key systems to cover typically include:

• Cardiovascular

• Respiratory

• Gastrointestinal

• Neurological

• Genitourinary/Renal

• Musculoskeletal

• Psychiatric

Some teaching approaches may include additional systems like ENT or Ophthalmology.

Step 09 – Summary of History
Conclude the history-taking by summarizing what the patient shared. Repeating key points allows the patient to confirm accuracy or clarify misunderstandings. Also, explore the patient’s beliefs about their condition and their expectations for the consultation. The ICE acronym (Ideas, Concerns, Expectations) is helpful here.

Step 10 – Patient Questions / Feedback
Allow the patient to ask questions during or after the history. It is crucial to avoid providing incorrect information. If unsure of an answer, state that you will consult with senior staff or find more information (like brochures) for them. This demonstrates honesty rather than guessing.

Step 11
Once you have sufficient information and the patient has asked their questions, thank them for their time and inform them that a doctor involved in their care will see them shortly.