Can you please give an example of how to take a history? Love your blog.
Hello! I hope I’m not too rusty, I haven’t taken a history in a while. So, taking a history varies a lot depending on the situation, the medical problem, the age of the patient. For example, if it’s a obs/gynae problem you’ll usually want to ask about previous pregnancies, if it’s psych then you’ll probably go more into their personal life, etc.
But we usually use the same standard formula and I’ll use an easy example - lets say someone who fell over and hurt their arm.
- don’t ever forget to introduce yourself and ask their name!
- start with the presenting complaint (i.e. what’s happened to them now). With pain, I really like using the SOCRATES acronym:
Onset (when did it start)
Character (like is it sharp, stabbing)
Radiation (does the pain radiate anywhere)
Associated factors (any symptoms associated with the pain)
Exacerbating or relieving factors
Severity (e.g. out of 10)
So that usually gets more of the info about the pain. And with any fall it’s always important to ask about how it happened. Depending on what they say, you might need to ask more questions. Remember, it’s not just about just asking your pre-set questions, it’s also about listening to the patient and responding to their answers. For example, if they mention they got a bit dizzy before they fell, pick up on that, ask them about it.
- then we usually move on to past medical history, which is pretty self explanatory. I usually say something like, ‘do you have any other medical problems’, and then maybe prompt them with something like ‘like diabetes, or high blood pressure?’ (high blood pressure is something patients often forget they have). In this situation, you might ask if they’d broken any bones before
- I usually then ask about medication history. Remember to also check if they buy any meds over the counter, or use any herbal remedies. Oh and in girls I find they often forget their contraception is a med, so maybe check for that. In this situation, you might check if they’ve used any pain meds for their arm.
- family history. E.g. I usually ask ‘does anything run in your family, like diabetes or heart problems?’ Remember to adapt it to the situation - e.g. if this is a patient with a DVT or something, ask if they have a FH of blood clots.
- social history. This will vary a lot depending on the situation. E.g. here, you might ask how their living situation is and if they’ll have people to help them if their arm is broken. Always ask about smoking and alcohol use (be specific with these - ask how many they smoke a day, for how long. How many drinks do they have a week).
- general health review - I like to use the acronym SAWTEM:
Mood (i.e. checking for depression, low mood)
- as well as the main facts, it’s important to also get the patients views. Something we use a lot is ICE (yes I love acronyms):
Ideas (what do THEY think is happening)
Concerns (what are they worried about - this is REALLY important to ask about and address)
Expectations (what do they hope/expect to happen now)
This is sooo important, it shows that you actually care what the patient is thinking, and helps to address their ideas and concerns. You can ask this near the end, or you can try incorporate it into the history. Again, pick up on things - e.g. they might say that they’re worried about something early on in the consultation, and instead of skipping over it you could delve into their concerns.
Another important thing to do is recognise and acknowledge their issues and feelings. This shows empathy, which is important in a doctor. It’s hard to sort of say how to do this, because it should hopefully come naturally, but yeah. Things like ‘i realise how hard this must be for you’ and ‘it’s understandable why you’re so worried’ etc. Validate their concerns.
- remember to look at their body language too. Do they look nervous? Sad? agitated?
- if they’re upset, give them time. Find them a tissue and some water, don’t press them to keep talking until they’re ready
- signposting. Examiners love this, and it makes more sense for the patient too. Things like ‘i’m going to ask a little bit about your lifestyle now’ etc, just so that there’s a bit more warning before you ask quite different questions
- summarise. I often do this after I’ve asked about the presenting complaint - summarise it back to the patient. This helps get it clear in your head, and also allows the patient to add stuff or correct you
- make sure you leave out the medical jargon! Even asking for their ‘past medical history’ sounds a bit wooden and they might not understand you. Use clear, normal phrases.
There’s loads more I could talk about but I’m gonna stop here before it gets too long haha! Hope it’s helpful. x
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