Taking a patient history
- Age, sex, name (good to know this before you see the patient)
- Then introduce yourself (Name, grade)
- One line, why is the patient here?
- For every symptom you want to know:
- When it started?
- Onset, was it sudden or gradual, what were they doing?
- Duration and is it intermittent or continuous?
- Progression, getting better or worse?
- Have they experienced this before? When, where, how, why, is anything different this time?
- SOCRATES for pain, and not the worst acronym to rely on if stuck with other symptoms
- Associated symptoms
- Time course
- Exacerbating/alleviating factors
- What else is going on?
- Is their current problem likely to be related to a condition they have/or have had?
- For chronic conditions, What is the diagnosis? When and how was it diagnosed? What is normal for them? What treatment are they on? What is the worst it has been? How is it now?
- For surgical histories, What diagnosis? When? What operation? Any complications?
- Never forget to ask about allergies (you will, but you'll soon learn not to)
- What are they allergic to? and what happens when they take/have taken it?
- Medications, this includes, over-the-counter medication, herbal medication and contraceptives
- Dose, frequency and indication
- Does anything like this run in the family?
- Are their parent's alive? Are they well?
- Consider drawing a pedigree diagram.
- Home arrangements, how independent is the patient and what help do they have at home
- Smoking, alcohol and illicit drugs, if yes to any you need to ascertain, frequency, quantity and duration of use
- Foreign travel, if suspicion of something travel related ask about close family members, or friends recent travel
- Ask about symptoms that will narrow your differential diagnosis.
- What does the patient think is going on?
- Is there something that is particularly bothering them?
- What are they hoping for?
- A good history will more often than not lead you to the diagnosis. When taking a history you want to be thinking about your differential diagnosis and asking relevant questions that will help narrow this down.
- From your list of differentials what information do you now need to confirm or exclude your diagnosis?
- What systems do you need to examine?
- What bedside tests will you do?
- What investigations will you order?
- Is there any treatment you want to start?
- This is a generic guide to taking a history and will lead to a very thorough history, for medical students it is really recommended to take detailed histories, you are establishing a huge database of clinical details and you should assume everything is relevant.
- Exams and wards are two different battlefields and you will find your approach differs greatly,