How to take a history

Start by putting the patient at ease:

• Greet the patient by name: "Good morning, Mrs Jones"
• Introduce yourself and explain that you are a medical student.
• Shake the patient's hand, or if they are unwell rest your hand on theirs.
• Ensure that the patient is comfortable.
Standard history taking

• Name
• Address
• Date of birth
• Date of admission
• Presenting complaint
• History of presenting complaint
• Previous medical history
• Systems enquiry
• Drug history and allergy
• Family history
• Social history
• Conclusion/summary

General questions to ask the patient:

• Tell me what seems to be the problem.
• How long have you been unwell?
• When did the symtoms start?
• Not What brought you here?

History of presenting complaint
If the history of the presenting complaint includes pain, ask about it using the
mnemonic SOCRATES
• Site - where exactly is this pain?
• Onset - when did the pain start, did it start suddenly or gradually?
• Character - describe the pain - sharp? knife-like? gripping? vice-like?
burning? crushing?
• Radiation - does the pain spread anywhere? To the arm, jaw, groin
etc?
• Associations - is the pain accompanied by any other features?
• Timing - does the pain vary in intensity during the day?
• Exacerbating and relieving factors - does anything make the pain better
or worse?
• Severity - does the pain interfere with daily activities or with sleep?

Questions to ask about previous medical history

General question:

• Have you suffered from any previous illness?
Medical
• Ask about childhood illness and immunization
• Have you had TB or whooping cough?
• Have you ever been found to have high blood pressure?
• Have you had rheumatic fever?
• Have you ever suffered from epileptic seizures?
• Do you get asthma (episodic breathlessness, usually with wheeze)?
• Have you suffered from anxiety or depression?
• Do you have diabetes?
Surgical
• Have you had any operations in the past?
Obstetric (where appropriate)
• Have you had any pregnancies?
• Were they normal?
• Were there any complications such as hypertension and toxaemia,
diabetes, Caesarian section?
You may find the mnemonic THREAD helpful:
• Tuberculosis
• Hypertension (myocardial infarction and strokes)
• Rheumatic fever
• Epilepsy
• Astham, anxiety and arthritis
• Diabetes and depression


Systems Enquiry

Questions to ask patients about their general health:

Cardiovascular and respiratory function
• Do you have a cough?
• Do you cough anything up?
• Have you ever smoked? If so what, how many, and for how long?
• Do you get short of breath?
• Do you wheeze?
• Do you get any chest pain?
• Do your ankles swell?

Gastrointestinal function
• Has there been any change in your appetite?
• Has there been any change in your weight?
• Have you suffered from nausea or vomiting?
• Has there been any change in the character or frequency of your bowel
movements?
• Has there been any change in the colour or consistency of your stools?
• Have you had any bleeding? - while vomiting (haematemesis) or
rectally?

Genitourinary function
• How often do you pass urine?
• Do you have pain or burning on passing urine?
• Do you have pain in the small of your back (renal angles)?
• Is there any blood in your urine (haematuria)?
• Do you have any sexual problems?

Specific questions for men
• Do you have any penile discharge or venereal infection?
• Do you have any difficulty starting to pass urine (hesitancy or urgency),
maintaining the flow of urine (poor stream), or stopping the flow of urine
(terminal dribbling)?

Specific questions for women
• Do you have any vaginal discharge?
• When did your periods start?
• Are your periods irregular?
• How often do your periods occur and for how long do they last?
• Do you have heavy bleeding (menorrhagia) or do you pass clots during
your period?
• When did your periods stop (menopause)?
• Have you had any bleeding since your periods stopped?
• How many children have you had and when did you have them?
• Did you have any complications during any pregnancy?

Musculoskeletal function
• Have you any weakness in your arms or legs?
• Do you have any stiffness in your joints or spine?
• Do you have pain in your joints or spine?

Neurological function
• Do you have any headaches?
• Have you had any blackouts?
• Have you had any fits?
• Have you had any dizziness (feeling of instability or rotation)?
• Do you get ringing in your ears (tinnitus)?
• Do you get abnormal sensations or tingling in your hands or feet
(paraesthesia)?
• Have you noticed changes in your sense of hearing, smell, taste,
vision?
• Have you any incontinence of urine or stools?
• Do you get depressed?
• Do you get anxious?

Drug history and allergies
• What drugs, homoeopathic and herbal medicines and/or health foods
do you take? - and in what dose?
• What other therapies do you have? - Physiotherapy? Occupational
therapy? Malaria prophylaxis?
• Do you have any allergies?
• Have any medicines ever upset you?
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Family history
• Are your father, mother, brothers, sisters alive? - If they have died, at
what age did he/she/they die? What did he/she/they die of?
• Do they have any current illnesses?
• Do any illnesses run in your family?
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Social history
• Who is at home with you?
• Are you single, married, widowed or divorced?
• Is your partner healthy?
• How many children have you got?
• Are your children healthy?
• What is your occupation?
• Do you have any financial worries?
• Do you smoke? - If so, how may per day/week?
• Have you ever smoked? - Why did you give up?
• Do you drink alcohol? - If so, how many units per day/week?
• Have you been abroad? - If so, where?
• Do you have pets?
• If mobility is a problem: What is your home like? Do you have to
manage stairs? What facilities have you got?

Conclusion/summary
After you have taken the history summarize your findings under appropriate
headings. Once you have completed the history ask the patient whether they
have any other particular worries or concerns that you hve not discussed.
Thank the patient and explain, if appropriate, that you would now like to
examine them.

Summary

Date and time
Place of
consultation
Patient's name, age
and occupation
Presenting
complaint
Summarize both the current problem and the means by which the
patient came to medical attention
e.g. - referred by GP, with a 3 hour history of severe central chest
pain, - brought to the Accident and Emergency department by
boyfriend after taking an overdose of paracetamol
History of present illness
Detailed account of current problem
If complaint is pain, remember SOCRATES
Systematic enquiry
Take detailed supplementary questions if responses are positive
Cardiovascular and respiratory
Gastrointestinal
Genitourinary
Neurological
Musculoskeletal
Psychiatric assessment (where appropriate)
Past medical history

Medical:
• TB
• Hypertension
• Rheumatic fever
• Epilepsy
• Asthma
• Diabetes
Surgical
Obstetric
Family history Age and state of health of parents and siblings
Social,
occupational and
travel history
Drug and therapy
history include allergies