How to take a good medical history 

How to take a good medical history 

Asking questions (or as we call it ‘taking a history’) is a doctor’s most important skill. Full stop.

Why? 80% of the diagnosis comes from the history (10% examination, 10% tests).

History taking is about knowing the questions to ask, careful listening to the answers (and recording them). It takes a long time to get good at it – at least ten years after a doctor qualifies [“sorry any student reader! MyHSN Ed”]. This is why it’s vital for doctors to get a lot of experience.

This can only be gained by seeing many, many patients especially in pressure situations like A&E, a GP or hospital outpatient clinic – with you leading the questioning. Watching experienced doctors can help a lot too. Note the questions that lead to useful and less useful answers.

The patient needs to like and trust you, for your history taking to be effective.

This is the structure for the questions we recommend:

1. Introduction
2. Presenting complaint (PC)
3. History of presenting complaint (HPC)
4. Past surgical history (PSH)
5. Past medical history (PMH)
6. Drug and allergy history (DH)
7. Social history (SH)
8. Family history (FH)
9. Ideas, concerns and expectations (ICE).

So. How to take a medical history.

Preparation before questions

Before you start .. stop, slow down, and think. Just for 15 seconds. What equipment or data do you need? What does the room look like? Does it instill confidence? Do you? Is the hospital database on and accessible?  Have you reviewed previous letters? Is there gel to wash your hands etc?

Now you can ask questions. Here we go. We will now expand on these question groups, and go through how to take a medical history (in 10 questions); focussing on some actual questions to ask, and why we ask them.

These questions can be used in a clinical or examination setting.

1. Introduction

“Hello, my name is XX and I’m a YY student. You name is ZZ and you are AA years old. Is that correct?”

Why
You need to check that this is the patient you think it is, and they should know your name as well. Their age is key too, as different diseases are more or less common at different ages. Asking their date of birth wastes time, as it causes you to have to do mental arithmetic on their age.

Notes
(1) The introduction (and start in general) is very important, as sets the tone for the whole history, and starts communication based on trust. Without trust, nothing is possible
(2) A handshake is important. It’s partly a greeting but also part of the examination. Some diagnoses can be made by the handshake and subsequently looking at the hands and nails
(3) Style is important – friendly (not friends), open, polite (lots of ‘thankyous’ and ‘pleases’) is best. You can use gentle humour when you have the patient’s confidence. Do not eat or drink or check your mobile in front of them. A bag chucked in the floor looks messy. Are you appropriately dressed with clean nails? Make sure they can see the computer screen that you are using, but it does not get in the way of your eye line.

Why
Listen very carefully. Write the answer down. This is the most important question in the history for two reasons: (1) the diagnosis is often within it; (2) it’s the patients major concern (so it has to be addressed, for them to trust you).

Note. You ask this question having established a rapport in the introduction. Do not start with it.

3. History of presenting complaint (HPC)

The questions should link to, and expand on, the primary complaint. They should help you pull out other symptoms that help with the diagnosis. The patient may not realise these are relevant. There is no single ‘correct question’ for the HPC. It depends on the problem. But the following one is a good one to start with.

Question
“Please describe the problem in more detail, is it linked to anything, and what makes it better or worse?”

Other questions (examples)
“Did it start gradually, rapidly or suddenly?” (these are the three rates of onset)
“Where is the problem?”
“Have you has this problem before?” (it may be a recurrence of an old problem)
“Have you noticed any other symptoms?” (e.g. if the primary issue is shortness of breath, “any chest pain or ankle swelling?”)

If it is a pain, these are three important questions:

• “Point to where the pain is worse”
• “What makes it better or worse?”
• “On a scale of 1-10, how bad is the pain, when 10/10 is the worse pain you have ever had?”

Note. Asking about the type of pain is rarely helpful: partly as people have different pain thresholds; and partly, as what is ‘heaving’ for one, is ‘sharp’ for another.

Why
The three most important features of a problem are: duration and speed of onset, and site. These are key to the diagnosis (i.e. how long, how fast and where). For example, six months of a gradual onset of low back pain, is osteoarthritis. A week of a rapid onset of low back pain (at the same site), is a prolapsed lumbar intervertebral disc.

Notes
(1) The question above is better than “how long have you had this problem?”. The word ‘first’ prompts them to think about the onset, and the time when they didn’t have the problem
(2) Even so, patients often have difficulty remembering when a problem started. So you may have to prompt them, e.g. “Two weeks ago?” (four weeks? A month? Three months? etc)
(3) If you are not getting anywhere with dating the onset, asking “when were you last reasonably well?” can help
(4) Less severe problems of less than two weeks often get better of their own accord, and no diagnosis is made.

4. Past surgical history (PSH) 

Ask about operations first, or you will forget.

Question 
“What major operations have you had?”

Notes
(1) If you don’t say the word ‘major’, they tell you long lists of minor operations and procedures
(2) Women are tough. They don’t think a PE after a Caesarean section is important, as they don’t think a PE is an illness and a caesarean, an operation. Men would call it a major lung clot after a laparotomy (they are). I.e. it’s worth pushing this PSH question, with “are you sure that’s it? anything else?” etc.

5. Past medical history (PMH)

Question 
“Have you ever had diabetes, jaundice, anaemia, TB, CKD, heart attacks or strokes, high blood pressure, rheumatic fever or ulcers in tummy?””

Why
You are trying to find out:
(1) if there are any risk factors for the diagnosis you are considering (increasing their likelihood);
(2) the current problem is a repetition or consequence of a previous one.

Notes
(1) Some of the PMH questions are designed to ‘open up’ other areas, e.g. asking re Rheumatic Fever will jolt their memory on Rheumatoid Arthritis
(2) Asking generic questions like “any medical problems?” or “do you see the doctor for any condition?” are unhelpful. Think about it, what would you say if asked that question (e.g, “like what doctor?”).

6. Drug and allergy history

Question
 “Please tell me your current medication (or preferably show me a list if you have one) and are you allergic to any drugs”

Why
An accurate drug history is vital. Why? Medication is the cause, or part of the cause, of illness in up to 20% of cases. So stopping drugs is as important as starting them. You do not want to give the patient a drug that they are known to be allergic to.

Note
Asking “have you got any allergies?” is not a good question – unless you want a long discussion of their hay fever, and its possible causes.

7. Social history (SH)

Questions
“Are you married?”
“How many children to you have?”
“Who do you live with?”
(If appropriate) “do you have carers, or meals on wheels?”
“What is your job OR what was your last job?”
(If appropriate) “have you travelled abroad recently?”

Followed by ..

“Have you ever smoked?” (“do you smoke?” is not a good question; it is too open to return questions)
“Have you ever been a regular heavy drinker?” (“do you drink?” is also not a good question, for the same reason)
“Have you ever taken any recreational drugs?” (if, yes, what?).

Why
The function of the social history is to paint an accurate and complete picture of the patient’s home environment and lifestyle. Excessive smoking and drinking alcohol can point you towards specific diagnoses.

Then ..

Question
“Have you ever smoked, and have you ever been a regular heavy drinker?”

Other questions
“Have you ever smoked?” (“do you smoke?” is not a good question; it is too open to return questions)
“Have you ever been a regular heavy drinker?” (“do you drink?” is also not a good question, for the same reason)
“Have you ever taken any recreational drugs?” (if, yes, what?)

8. Family history (FH)

Taking a family history is essential to determine illnesses that run within the family or may be inherited.

You need to change the questions according to the patients age, eg:

• Age under 30 .. “do your parents have any major medical problems?”
• Age 30-70 .. “are your parents still with us?” If so, “do they have any major medical problems?”
• Age 70+ .. “what did your parents die of?”

And follow with these questions:

• “Any diseases in the family that pass through the generations?”
• “Any funny or rare diseases in your family?”

Sometimes a hyper-specific question is useful and should be added, e.g. “has anyone in your family had kidney dialysis or a kidney transplant?” (looking for polycystic kidney disease).

9. Ideas, concerns and expectations (ICE)

Question
“What are your ideas about what’s going on, and your concerns and expectations (of us)?”

Other questions
I. “What ideas do you have about what is wrong with you?”
C. “What are your biggest concerns?”
E. “What do you wish to happen from now on?”

Why
These questions enable you to hear the patients ideas. They know their body better than you. So they may be able to help you, i.e. they may have made a correct diagnosis. Also they tell you the concerns you need to address.

Systems review (SR) – optional

Questions (examples)
“Have you had any shortness of breath, chest pain, palpitations, ankle swelling, cough or sputum?”
“Any problems with your bowels or waterworks (and periods in a woman)?”
“Any blood in your wee or poo?”
“Any headaches, fits, falls or dizzy spells?”
“Any lumps, bump or rashes anywhere?”

Why
This is a difficult part of the history. You are asking about all the systems of the body, not covered above in the PC and HPC. If you do it properly, it can take a long time and take you away from more productive lines of questioning. Or worse, it can give you unnecessary information that you then over-focus on, leading to an incorrect (or multiple) diagnoses.

Notes
(1) As doctors get more senior, they largely drop this section, apart from picking out one or two specific questions
(2) For example, they may use this part of the history to ask about ‘Red Flag’ symptoms like blood in the urine or faeces
(3) Asking about how many times they wee or poo is often hard to answer (how many times do you wee or poo? “thanks, MyHSN Ed”). It is the change of their normal pattern you are looking for.

General points

(1) Even though ‘open questions’ are encouraged in medical training, they are vague, so lead to vague answers. Most doctors (especially GPs) are under time pressure. So you learn to ask the more specific ones above
(2) If there is a partner, friend or relative there, encourage them to come in. They will add information and help the patient remember what you said
(3) If it is an outpatient assessment, at the end of the consultation, write things down for them: key conclusions including the diagnosis, what you want them to do, and how to contact you later, if they don’t understand anything. This hugely increases the likelihood that you plan is carried out. This is in addition to the formal medicolegal letter that should follow all assessments. Handwritten notes can be given to patients on ward rounds and clerking areas (e.g. A&E) as well.

Presenting a summary of the medical history

This is a skill too, as important as actually taking the history. We recommend a ‘5 sentence summary method’. This is an example:

1. Introduction/PC. Mr X is a 47 year old astronaut who presents with a 6 hour history of a rapid onset of chest pain (pause, 1000, 2000 in your head)
2. HPC. He has been getting exertional chest pain for 6 weeks, getting more frequent (pause etc)
3. PSH/PMH. He has Type 2 diabetes, but there is no other history (pause)
4. SH/FH (if relevant, or leave out). He is an ex-smoker (pause)
5. 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).

Notes

(1) You will need this skill on ward rounds, and 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)
(2) A good history is one that can be repeated – 6 hours or more later by the listener remembering 80% or more of it
(3) Don’t say ‘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
(4) Never say ‘the patient is a ‘poor historian’. The ‘poor historian’ is you. The patient is the witness. You are the historian. So if you have not obtained a good history, it is your fault. Do it again
(5) There is no point in taking a good history, unless you can present it well. Practice, practice, practice (practice!).

Finally. Doctors don’t do adverbs, or make assumptions.

Oh yes. When you present please try to avoid loose adjectives and adverbs, e.g. it is OK to present a ‘patient with epilepsy, diabetes, an alcohol problem or obesity’. They are not an ‘epileptic, diabetic, alcoholic or obese’ person. These are judgemental terms which describe and define the patient by their disease. Would you like to be labelled diabetic?

Do not make assumptions, e.g. just because the patient is a middle class professional. The nun is as likely to have syphilis as the prostitute. Maybe not 100% true. But you get what we mean.

Summary

We have described how to take a good medical history, and how to present it. History taking is a doctors most important skill. You will get better at it. That takes years.

Other resource

This is a good video by Professor Vinod Patel at the University of Warwick.