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General history

Chief complaint Brief statement of the reason for the patient encounter

Past or chronic illnesses, injuries, surgeries

Past medical history Developmental history (as appropriate)
Obstetric history (as appropriate)

Prescription & over-the-counter drugs, vitamins, supplements

Medications & allergies Allergic reactions to medications or other medical agents
Significant environmental or food allergies

Family history Medical issues that may affect the patient

Marital status, living situation, social stressors

Social history Occupation, employment status
Tobacco, alcohol, drug use

Full description of the problem:

Location
Quality
Severity
History of present illness Onset/duration
Course over time
Triggering/modifying factors
Context
Associated symptoms

Review of systems List of symptoms (present & absent) in other body systems

The patient encounter should begin with a friendly introduction and greeting:

"Hello Mr. X. Good morning/good afternoon. I am Dr. Y. It's nice to meet you (shake hand)."

The early parts of the patient interview should emphasize open-ended questions; more specific or yes/no
questions are used sparingly later in the interview, primarily to rule in or rule out specific possibilities in the
differential diagnosis. Use brief transition sentences to direct the flow of the interview, and obtain
permission from the patient before probing sensitive matters (eg, "To better understand your current
problem, I would like to ask you a few questions about your recent sexual encounters. Is that all right?").

All patient interviews should start with the chief complaint (CC). Some clinicians prefer to perform the
history of present illness (HPI) next, to clarify the CC in greater detail before going on to past medical,

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family, and social histories (PFSH). Other clinicians ask about PFSH before the HPI to better understand the
patient's background and find clues to guide the HPI. Either strategy is acceptable, but it is usually best to
take a history in the same order each time to avoid missing important information.

All patient encounters should include a CC, HPI, PFSH, and review of systems (ROS). According to the
USMLE, you will not have adequate time to conduct a complete history and physical examination, and
scoring of the exam does not assume that you will do so. However, these core elements should be addressed
in each encounter, with the level of detail in each element tailored to the specific encounter.

Chief complaint

Use a simple, open-ended question:

"Can you please tell me what we can do for you today?"

"What can we help you with today?"

The CC should guide the rest of the interview, with the overall history intelligently conducted to tell a
coherent story of the patient's primary problem. However, the clinician should stay alert to additional
concerns the patient may bring up, which occasionally may be more important than the initial CC. If a later
issue is actually of greater importance or concern to the patient, it should be used as the CC when
documenting the encounter.

Past medical history

Begin the discussion of past medical history (including surgical history) with general, open-ended
questions:

(Transition sentence) "Before we continue, I would like to get a little background information about
you so that I can understand your present problem."

"For what medical conditions have you seen a doctor or been in the hospital?"

"Have you had any operations in the past?"

Follow this with specific questions relevant to the CC:

"Has anyone told you whether you have high blood pressure, high cholesterol, or diabetes?" (eg, for a
patient with chest pain)

Some patients may not initially offer information about sensitive subjects, such as reproductive history, sexual
history, and psychiatric history. Although many patients will require only cursory questioning on these
subjects, you should be prepared to interview the patient in more depth depending on the primary problem.
(More details regarding the obstetric/gynecologic, sexual, and psychiatric histories are included in those
sections of the Step 2 CS course.)

Medications

Obtain a list of all medications the patient is currently taking or recently took, including over-the-counter
medications, vitamins, and nutritional supplements:

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"Are you taking any medications that a doctor has prescribed for you?"

"Are you taking any vitamins, supplements, or over-the-counter medications?"

"Have you taken any other medications that were recently discontinued?"

Allergies

Ask the patient about any allergies to medications, medical agents (eg, radiologic contrast agents), and
significant nonmedical allergies:

"Are you allergic to any medications?"

"What allergic reaction does the medication cause?"

"Are you allergic to anything in the environment or any food?"

Family history

As with past medical history, you should begin with general, open-ended questions followed by specific
questions as appropriate. Questions should primarily focus on first-degree relatives (parents, siblings,
children) but may expand to more distant relatives as needed (eg, suspected genetic disorders):

(Transition sentence) "Now I would like to ask you about your family."

"How old are your parents? What medical conditions do (or did) they have?"

"How many brothers and sisters do you have? Do any of them have any medical conditions?"

(For a patient with possible diabetes) "Is there anyone in your family with diabetes?"

Social history

Social history covers the patient's living situation (including marital and sexual histories, as appropriate),
occupation, education, and social stressors. The interview should emphasize nonjudgmental, open-ended
questions:

(Transition sentence) "I would like to ask you about your living situation."

"Who do you live with at home?"

"Are you working? What kind of work do (or did) you do?"

All patients should be asked about tobacco, alcohol, and illicit drug use. Again, use nonjudgmental, open-
ended questions to start and follow up with more specific questions as needed:

"Do you smoke or use other tobacco products?" "How much do (or did) you smoke, and for how many
years?" "At what age did you start (and/or stop)?"

"Do you drink alcohol?" "How often?" "How many drinks do you have when you do drink?" "At
what age did you start drinking?"

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"Do you use any recreational drugs, or did you in the past?" "What do (did) you use?" "When did you
start (stop)?"

(For all substances) "Has your use of ___ led to any additional problems (eg, arrests, family problems,
job problems, medical complications)?"

"Have you had any blood transfusions?" "Have you had any tattoos?"

History of present illness

As with PFSH, begin with a transition sentence, use primarily open-ended questions, and follow up with more
specific questions as needed:

(Transition sentence) "Now that I have your background, l will focus on what brings you in today."

"Tell me more about your chest pain."

The HPI interview should cover the location (including radiation) of the symptoms, quality, severity (numeric
or descriptive), onset/duration, triggering/modifying factors, course over time, context (what the patient is
doing when the symptoms occur), and associated symptoms. It is recommended that these features be
addressed systematically, although not all will be relevant for every problem (eg, "fatigue" does not have a
"location").

(Location) "Where is your pain?" "Can you point to where the pain is coming from?" "Does the pain
go anywhere from there?"

(Quality) "What does the pain feel like?" "Does this remind you of anything you felt before?"

(Severity) "How bad does it get?" "On a scale of 1 to 10, how painful is it right now?" "Is it severe
enough to limit your activity?"

(Onset/duration) "When did you first notice this problem?" "When was the last time you felt
completely healthy?" "How long does this last when it hits you?"

(Course over time) "Is it constant, or is it happenning on and off?" "How often do you have
symptoms?" "Is it getting better or worse over time?"

(Triggering/modifying factors) "Can you think of anything that seems to be triggering this?" "Is there
anything that seems to make it better or worse?" "Have you tried any home treatments for it?"

(Context) "Does it happen only at particular times, or in particular situations?" "Does anyone around
you have similar symptoms?" You may also wish to clarify directly related past history and risk
factors. "Does this relate to any other health problems you have?"

(Associated symptoms) "Have you noticed any other symptoms along with this?" You will usually
need to inquire about specific important symptoms (eg, for a patient with a cough, you should ask about
fever, hemoptysis, dyspnea, wheezing, etc).

Unless patients are unusually tangential or incoherent, they should be allowed to tell their story without
interruption. Most patients will not take more than 1 or 2 minutes to explain HPI and often will cover most of
these key features spontaneously.

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Review of systems

After obtaining the HPI, all patients in Step 2 CS should have an appropriate ROS. However, the level of
detail for each system will depend on the patient's primary problem. Related or adjacent systems warrant
detailed and specific questioning, whereas unrelated systems may need only a few cursory questions. For
example, for a patient with a cough, all pertinent positives and negatives should be included for ear/nose
/throat, allergic/immunologic, pulmonary, and cardiovascular systems, whereas musculoskeletal and
genitourinary systems may be addressed more briefly and generally. If time is short, you may obtain ROS
while performing the physical examination of the corresponding systems, but this should be done sparingly to
avoid appearing rushed. More detail regarding the ROS interview is included in the Complete ROS section of
the Step 2 CS course.

Summary and plan of action

Following the patient interview, summarize the history with the patient. Briefly discuss your concerns, what
you will be looking for on the physical examination, and what your plan of action will be to evaluate and
manage the problem. It is often helpful to ask if the patient has any additional concerns you may have
missed. For example, for a patient with a cough and history of asthma, you might say:

"Let me make sure that I have the correct details. You were well until 5 days ago when you started
having a fever, cough, and shortness of breath. This is similar to asthma attacks you have had in the
past, and you have a number of relatives who also have asthma. However, your usual asthma inhalers
have not relieved your symptoms. I am concerned that you may have a pneumonia. Are there any
additional possibilities you are concerned about before I examine you?"

Tips for effective history taking

Use plain English terms for medical conditions (eg, "high blood pressure," "swelling in the feet")
rather than medical jargon (eg, "hypertension," "pedal edema").

Use the patient's own vocabulary for bodily functions and sensitive or embarrassing subjects, rather
than sanitized or more formal terms (eg, if the patient uses the word "poop," continue to use that word
in the conversation, rather than correcting the patient to say "feces").

Be prepared with standardized questionnaires or mnemonics for common scenarios (eg, "CAGE"
questions in suspected alcohol abuse, "SIG E-CAPS" questions in suspected depression).

Tailor the history to the differential diagnosis. Spend more time going into detail on subjects related to
the patient's main problem, and avoid wasting time on minor issues. Each section and question should
help rule in or rule out diagnostic possibilities and make each possible diagnosis more or less likely.

Educational objective

Begin the medical history with a friendly introduction and greeting. Use brief transition sentences between
sections of the history. Emphasize open-ended questions, and use more specific yes/no questions sparingly to
clarify important details. The history for all patients should include a chief complaint, history of present
illness, past/family/social history, medications, allergies, tobacco/alcohol/drug use, and a review of systems.
The history should be done systematically, although the level of detail on each subject may differ depending
on the specific patient's problems.

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