Medical history taking: structure and mnemonics

Medical history taking: structure and mnemonics

This article is about medical history taking. The history is vital. Full stop. It is the most important skill of all doctors. Everywhere. Every day.

Background

Why? 80% of the diagnosis is in the history (10% examination, 10% tests) – so it is your key diagnostic weapon.

Also, as the placebo effect (convincing the patient that they will get better) is 50% of your healing power (and that comes from the history), you are foolish not to maximise the placebo.

The art of medicine is to determine why a patient has sought help, by taking a medical history.

The key skills to help establish the underlying cause of a patients’ symptoms (the diagnosis) is based on:

1. Talking to the patient (history)
2. Examining the patient (examination), and
3. Requesting tests – like bloods and x-rays (investigations).

The information gathered from the history and examination is used to form a hypothesis of the possible underlying diagnosis.

Investigations can then be used to either confirm or refute this initial diagnosis. Some diagnoses can be made just by talking to a patient; whilst others are reliant on a specific test.

As a medical student, student nurse, physician associate (PA), advanced clinical practitioner (ACP), or allied health professional (AHP), you learn the art of taking a formal history, examining a patient, and interpreting investigations.

The history is the most important aspect of the interaction between patient and doctor or health professional (HP).”

It is the cornerstone of the doctor/HP-patient relationship and relies on good communication skills.

We will now describe the basic structure of history taking in medicine that is used by all clinicians. We will also give you mnemonics and lists to remember aspects of the history. After many years of history taking, the relevant questions will be in your head. But it takes a lot of experience to get to that point.

History structure

Taking a history from a patient – i.e. talking to the patient about their medical complaint and past medical problems – is the most important skill for all clinicians.

The history has a well-formulated structure to help determine the patient’s problems in a logical order; and to establish any other relevant information (i.e. previous medical problems, medications).

It helps to sign-post key parts of the history. It also provides a structure so you can present information to another health professional (another core component of medical practice) in a way they will understand.

The basic structure of the history has 9 sections, in a specific order. This is as follows:

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

1. Introduction

It is very important to start well.

Question
“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 also very 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. This is called a diagnostic handshake
(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.

2. Presenting complaint (PC)

The PC should be a single sentence that describes the reason why a patient has sought help. An example of a typical PC would be abdominal pain or headache.

The information helps to focus the potential list of causes. It should be presented in this way:

• “88 year old female presents with a 1 month history of right upper abdominal pain” (gall stones probable)
• “23 year old male student presents with a sudden onset of 12 hours history of frontal headache” (subarachnoid haemorrhage probable)
• “56 year old male heavy smoker presents with a single episode of haemoptysis” (Ca lung probable).

3. History of presenting complaint (HPC)

The HPC is the key part of the history of which the clinician should spend most of their time determining the nature of the complaint.

You should ask a series of both open and closed questions to further clarify the problems being faced by the patient. Key questions may include:

• “Could you tell me more about this symptom?”
• “How long has the symptom been affecting you, and have you had it before?”
• “What makes the symptom better or worse?”
• “Is it associated with any other symptoms?”.

In general, the HPC can be targeted depending on the presenting problem. You always need to determine the chronicity and associated features of any problem. If it is pain, you need to take a pain history. See below.

Speed of onset of symptoms
This is very important. For example, pains come on either suddenly (‘like a bus hitting you’), rapidly (‘over a minute or two’) or gradually. For chest pain, there are only three causes of a sudden onset; aortic dissection, pneumothorax or oesophageal rupture. An MI or PE usually comes on rapidly.

Duration of symptoms
It is essential to determine when the problem started, how long it has been going on for, whether it is constant or comes and goes, and whether it has been worsening or getting better.

Associated symptoms
Always ask about associated symptoms such as nausea and vomiting, breathlessness, or fever. As you learn more about clinical medicine you will learn what the important questions are to ask.

Pain history (SOCRATES)
Pain is an extremely common symptom, and it is essential that all clinicians can take a good pain history from a patient. The key parts to a pain history can be remembered by the mnemonic SOCRATES:

• S – Site of pain. This is often where the cause is based
• O – Onset of pain. There are three speeds: suddenly, rapidly and gradually (see example above)
• C – Character of pain (e.g. sharp, dull, cramping). This is rarely helpful as pain is subjective and felt differently by different people
• R – Radiation (e.g. spreads from one site to another)
• A – Associated symptoms (e.g. breathlessness, nausea, vomiting)
• T – Timing (e.g. seconds, days, weeks)
• E – Exaggerating & relieving factors (e.g. worse on lying down)
• S – Severity (e.g. on scale of 1 – 10) – ‘where 1 is a mild headache and 9 or 10 is a major fracture, having a baby or the worst pain you have ever had’.

System-specific questions
These are groups of questions that should be asked when a patient presents with a particular complaint. They can be grouped based on organ systems (e.g. cardiovascular, respiratory).

For example, if the problem is related to the heart or lungs, you need to ask system-specific questions – and ask about SOB and ankle swelling if chest pain is the primary problem.

4. Past surgical history (PSH) 

It is best to start with the past surgical history, or you will forget: ‘What major operations have you had?” With women, they often have to be asked twice, as they tend to downgrade (or forget) operations like a caesarian, D&C or TOP.

5. Past medical history (PMH)

The past medical history is used to determine any previous medical problems that the patient has had within their lifetime.

To start this part of the history, it is useful to ask the patient specifically about 10 common conditions using the mnemonic HUJ-THREADS, saying “have you ever had ..

• H – Heart attack
• U – Ulcers in the tummy
• J – Jaundice
• T – TB
• H – High blood pressure
• R – Rheumatic fever (this can lead to answers related to rheumatology as well; this can be useful)
• E – Epilepsy
• A – Anaemia
• D – Diabetes, or a
• S – Stroke”.

You may need to ask about other chronic diseases like CKD, COPD, asthma and hypothyroidism.

It is important to determine each problem, when it started, the treatment required and whether there is any ongoing follow-up. Two examples are shown below:

• Myocardial infarction (heart attack). Diagnosed in 2006. Underwent percutaneous coronary intervention (PCI). Had two stents placed. Seen in cardiology clinic yearly.
• Gallstones. Diagnosed in 2004. Underwent a cholecystectomy (gallbladder removal) in 2005. No further issues.

Non-specific questions like “are you under the doctor for anything?” or “any medical conditions?” are not helpful.

6. Drug and allergy history (DH)

The medication history is used to establish what the patient is taking including both prescribed and over-the-counter (i.e non-prescribed) medications.

For all medications you need to establish the name, dose (i.e. mg/mls/mcg), frequency (i.e. once a day, once a week), and route (oral, intramuscular, intravenous).

The three things to ask about:

• Prescribed medications
• Over-the-counter medications
• Herbal or traditional remedies.

Always establish concordance (i.e. is the patient actually taking their medications), any side-effects and any recent changes (e.g. medications that have stopped or been started or dosing changes).

Ask about allergies as well: “have you ever had an major allergic reaction to a medication or tablet?”

7. Social history (SH)

The social history is one of the most important components of the medical history. The purpose 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.

You also need to consider the effects of their medical conditions on these social issues (i.e. new poor mobility due to heart failure may require a frame to walk, or worsening dementia may lead to increased carer input).

The key parts of the social history can be remembered using the mnemonic LOCAS DIET:

• L – life – who does the patient live with?
• O – occupation
• C – children – how many children does the patient have?
• A – alcohol
• S – smoking
• Di – diet
• E – exercise
• T – travel.

These are useful questions:

“Who do you live with?”
“Are you married?”
“How many children do you have?”
(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?).

Notes

Activities of daily living (ADL)
This refers to what the patient can do for themselves and how any illnesses may be affecting them. It is important to determine information such as whether they can wash and dress, can they go to the bathroom by themselves, do they have any carers, do they walk with any sticks or frames.

In older patients, the Rockwood Clinical Frailty Scale should also be used to determine how ‘frail’ a patient is based on their ability to complete personal or domestic tasks.

This is based on a patients’ capability two weeks ago and may need discussion with the next of kin or carer. The clinical frailty score is a reliable predictor of outcomes in patients’ presenting through emergency services. The scale runs from 1 (very fit) to 9 (terminally ill).

Alcohol consumption
This needs to be quantified based on a weekly average of alcohol intake. The national advice for both men and women is to not drink more than 14 units/week on a regular basis, with several alcohol-free days and a max of 3-4 units in any one day.

Screening alcohol dependence
A commonly used tool to assess alcohol dependency is called ‘CAGE’. This is a series of 4 screening questions that are used to determine the risk of excessive drinking or alcoholism. Each question equals 1 point.

• Have you ever felt you needed to Cut down on your drinking?
• Have people Annoyed you by criticising your drinking?
• Have you ever felt Guilty about drinking?
• Have you ever felt you needed a drink first thing in the morning (Eye-opener) to steady your nerves or to get rid of a hangover?

A score of ≥2 should warrant further assessment for alcohol dependence. In the inpatient setting, this would warrant assessment for alcohol withdrawal

Smoking history
Smoking history is described in the number of pack years.

A single pack-year is equivalent to smoking 20 cigarettes a day for a whole year. Therefore, if someone has smoked 20 cigarettes a day for 40 years, they have a 40 pack-year smoking history.

This can be explained by the following formula: pack years = (cigarettes smoked per day / 20) x number of years

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, expectations (ICE)

At the end of every consultation, you should enquire as to the ideas, concerns and expectations of the patient; that can be shortened to the mnemonic ‘ICE’.

Ideas
‘Do you have any idea about what could be going on?’

Ideas refers to the patients’ own thoughts about what the problem could be, and helps to guide your own diagnostic process.

Concerns
‘Is there anything which is concerning you at the moment?’

It is good practice to address any concerns a patient has during the consultation. It also helps to provide reassurance and offers time for the patient to ask any questions they might have.

Expectations
‘Was there anything you were hoping for from our discussion today?’

It is important to establish the patients’ expectations during or at the end of the consultation. For example, a patient presenting with a viral illness may be expecting to get antibiotics.

Note. There is no such thing as a ‘poor historian’. You are the historian, the patient is the witness. So if you have taken a poor history, through lack of skills and/or experience, the only ‘poor historian’ is you.

Systems review (SR) – optional

The systems review is a way of screening for any other symptoms related to major systems within the body.

The systems review can be completed at any point during the consultation but is usually completed at the end or following the history of presenting complaint.

It is important to ask brief, closed questions, to ensure you cover the major symptoms in a timely fashion. However, a positive response should be further investigated fully like in the history of presenting complaint.

The best way to approach the systems review is to start by asking three general questions, and then ask short closed questions from head-to-toe. These are three general questions are useful to screen for malignancy or chronic infections:

• W – Weight loss – have you had any significant weight loss recently?
• A – Appetite – has your appetite changed?
• F – Fever – have you had any fevers or night sweats?

The short, closed questions, can be based on a mnemonic CHAFRUL – i.e. “have you had any:

• C – Chest pain or shortness of breath
• H – Headaches, or visual or hearing problems
• A – Abdominal pain
• F – Fits, falls, dizzzy spells, or funny turns
• R – Rashes and joint problems
• U – Urinary or bowel problems (and periods in a woman)
• L – Lumps and bumps.”

As doctors (and health professionals) get more senior, they largely drop this section, apart from picking out one or two specific questions. For example, they may use this part of the history to ask about ‘red flag’ symptoms like blood in the urine or faeces.

Summary

We have described medical history taking: structure and mnemonics. We hope it has helped you. And thankyou for reading this article.