How to present a medical history
We will describe how to present a medical history.
It is a skill – and as important as actually taking the history. In fact, there is no point in taking a good history, unless you can present it well.
We recommend a ‘5 sentence summary method’. This is an example:
- Intro/PC. “Mr X is a 47 year old astronaut who presents with a 6 hour history of a rapid onset of chest pain” (pause, count ‘1000, 2000’ in your head)
- HPC. “He has been getting exertional chest pain for 6 weeks, getting more frequent” (pause, 1000, 2000 etc)
- PSH/PMH. “He has Type 2 diabetes, but no other history” (pause)
- SH/FH (if relevant, or leave out). “He is an ex-smoker” (pause)
- Diagnosis (or differential if you are not sure). “The most likely diagnosis is an acute coronary syndrome, or possibly a PE” (pause, do not move on to investigations or management, unless asked).
Wait for next question.
Tops tips on presenting a medical history
- All doctors need this skill – on ward rounds, in clinics and at 2am when you are talking to a grumpy consultant that you have just woken. You want him/her to take you seriously and not say “get the reg to ring me” (phone down)
- A good history – is one that can be repeated 6 hours or more later by the listener remembering 80% or more of it
- Do not mention ‘relevant negatives’ – unless very (very) relevant. For example, if you suspect cirrhosis, it’s useful to say “he drinks alcohol socially”, i.e. you are suggesting it is a non-alcohol related liver problem
- There is no such thing as a ‘poor historian’ – the poor historian is you. They are the witness
- So, if you do not have a good history – either start again, or find the history in another way – or both.
Practice, practice, practice (practice!).
Summary
We have described how to present a medical history. We hope it has been helpful.
