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Taking a history:

education ing issues such as:


G How they would like to be
addressed (forename or surname)
G Their physical comfort

Introduction and the G That you will treat all information

G
as confidential
How the patient may end the
consultation: “If at any time you

presenting complaint wish to stop this interview then


please let me know.”

Presenting complaint
Ask the patient to describe the symp-
tom or problem that brought them to
hospital by using an open ended
In the first of a two part series about taking a medical question: “What has happened to
history, Nayankumar Shah takes a look at the bring you to hospital?” or “What
introduction and the presenting complaint seems to be the problem?” You
should show interest to facilitate this.
Clearly, you want answers but you
also wish to develop a rapport with
the patient as well as understand him
or her (and you will not do this
through a series of closed questions).
The patient’s narrative gives
The clinical encounter usually con- able with. You are at liberty to re- important clues as to the diagnosis
sists of the steps shown in fig 1. A organise the order. For instance, you and the patient’s perspective of their
good history is very important for could go to the systems review after illness. You should not interrupt.
making a diagnosis. Examination and the history of the presenting com- Most patients’ initial response will last
investigations may help to confirm or plaint. Whatever order you use, how- fewer than two minutes. So it is worth
refute the diagnosis made from the ever, you need to ensure that you get while to give this amount of time to
history. all components of the history (fig 2). let the patient describe in their own
The history will also tell you about words the problem that has led to
the illness as well as the disease. The their present situation.
illness is the subjective component Introduction and details Thus, history taking involves the
and describes the patient’s experi- You should always begin by introduc- use of communication skills. You
ence of the disease. ing yourself. This should include need to develop your skills in:
Try to follow the sequence history, your status as well as the educational G Opening and closing a consulta-
examination, investigation when you reason for the encounter. For exam- tion
see a patient. A common mistake is ple, “My name is... I am a... year medi- G The use of open and closed ques-
to rush into investigations before cal student, and I have come to talk tions
considering the history or examina- to you to learn how to take a medical G The use of non-verbal language
tion. history.” G Active listening
It is easy to mindlessly order a bat- It is then useful to obtain some G Showing respect and courtesy
tery of tests. There are many prob- background information about the G Showing empathy
lems with this approach: patient including their name, age, G Being culturally sensitive.
G Investigations cannot be used in marital status, and occupation. This is not just an academic exer-
isolation—is the x ray finding or To establish rapport, and to put cise—management of the patient is
blood test result relevant or an the patient at ease, it often helps to dependent on these aspects. If you
incidental finding? continue the interview by consider- do not communicate properly you
G Investigations can be inaccurate—
there can be problems with tech- Fig 2
nique, reagents, or interpretation Components in
Outline of history taking Issues to deal with
of the findings taking a medical
G Investigations pose risks—radia-
history Introduction and
patient’s details
tion exposure, unnecessary fur-
ther procedures, and so on
G Investigations can be costly, to the Presenting complaint and Coping with illness
history of the presenting complaint
patient and to society.
Always remember to treat the
patient and not the investigation. Past medical and surgical history
And remember that although we talk
about “the patient,” you should con- Medications, drug
sider “the person.” history, and allergies

Smoking and alcohol history


Structure
You should use the following as a Fig 1 Steps in a
guide until you develop your own Social, occupational, How the illness has affected
clinical and family history psyche, personal life, family,
style and one that you feel comfort- encounter finances, and occupation

Systems review (inquiry)

History Examination Investigations Management


Conclusion and closure

314 STUDENTBMJ | VOLUME 13 | SEPTEMBER 2005


GARO/PHANIE/REX
education
Nobody likes will become increasingly frustrated diagnosis? To a large extent, this utes, hours, or days)
being disturbed and the patient will get suboptimal means making sense of the symp- G Progress, including frequency
at lunch, come care. So, when you are taking a his- toms that the patient presents with. and timing of the pain (constant,
back later tory, listen to the patient. Do they Sometimes the patient will tell you intermittent, etc)
know what is wrong with them? Do the diagnosis: “The doctor said that G Radiation of the pain
they understand the implications of I’ve got pneumonia.” Despite the pre- G Aggravating and relieving factors
this? What are their concerns and sumed diagnosis, it is worthwhile to G Previous occurrences
expectations? determine the symptoms or prob- G Associated symptoms (nausea,
Once you have determined what lems that led to this diagnosis: “So, vomiting, etc)
the presenting complaint is, it must what symptoms did you have?” G The patient’s notion of what is
be evaluated in detail. Some of the This is important as: causing the pain.
information required includes: G You can then attempt to link the An attempt should be made to
G When did the problem start (date symptoms to the diagnosis link the presenting complaint with
and time)? G The patient may have misheard the related systems review or
G Who noticed the problem or misunderstood the discussions, inquiry (see the second part in next
(patient, relative, caregiver, health and the diagnosis might be incor- month’s studentBMJ). For instance,
professional)? rect or only partly correct. a patient presenting with chest
G What initial action was taken by This leads to the rule that you pain should be asked questions cov-
the patient (any self treatment)? should always make your own ering the cardiovascular and respi-
G When was medical help sought judgment. ratory systems such as cough,
and why? You will find a great variety in shortness of breath, palpitations,
G What action was taken by the patients’ account of their illnesses. ankle swelling, etc.
health professional? Some keep meticulous details and Likewise, it is worthwhile to try and
G What has happened since then? can recall dates and times without determine any risk factors for the
G What investigations have been hesitation; others are vague even probable diagnosis. For example, a
undertaken and what are about details of their hospital stay. patient presenting with chest pain,
planned? This in itself is important: and suspected of having a myocardial
G What treatment has been given? G Does the patient understand their infarction, should be asked questions
G What has the patient been told illness? about smoking, hypertension, dia-
about their problem? G Have they been given sufficient betes, family history, etc. The aim of
This is not as easy as it sounds, information? this is to integrate your history, make
especially in the beginning. You need G Do they have dementia, delirium, a correct diagnosis, and ensure that
to be patient and practice taking his- or confusion? management takes into account all
tories. In the early years there is a Often, the patient will complain of the available information.
tendency to concentrate on events pain and there are specific character-
(investigations, treatments, etc) istics of pain that need to be elicited: Nayankumar Shah senior lecturer in general
undertaken after the patient has been G Exact site or location of pain practice, Newcastle, Australia
admitted to hospital. Although this is G Nature of pain (dull, sharp, etc) Nayankumar.shah@newcastle.edu.au
useful, what you should be aiming to G Onset of pain (sudden, gradual,
do is defining the problem. In other etc) The second part in next month’s stu-
words, what history would you take if G Severity of pain (can use a scale dentBMJ with deal with the other aspects
you were the first person to see the 1-10) of history taking, from the past medical
patient and had to make a differential G Duration of pain (seconds, min- history to closure of the interview.

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