Introduction

Background

The history is the first step in the management of a patient. As with many things, practice is key: hospitals are filled with patients, many of whom are more than happy to talk to students - so go and talk to them and practice! When you are taking a 'full' history, ensure that you follow a set pattern. This will help you remember all of the different sections. Once you've taken the history, make sure you also practice presenting it to someone. This involves presenting a concise summary of your findings, making sure to mention all relevant positive and negative features.

Writing it down

Some prefer to write down the history as they go along. However, this can be distracting and prevent you from making eye contact with the patient. As you improve, you will find it easier to remember the majority of the history, allowing you write it all up at the end. It can still be helpful to note down a few key points (e.g. dates or names) as you go along, to stop you forgetting them later. Finally, avoid the use of acronyms or abbreviations, and make sure that your writing is clear and in black ink (so that notes can be photocopied if required). Always sign and date any entries in the medical notes, and cross out any errors with a strikethrough (so that they are still legible) and sign/date them.

At the start...

Introduce yourself to the patient, and check that you have the right patient (i.e. by checking their name, date of birth, sex, ward and bed number). Then take their consent to take a history: e.g. "Do you mind if I ask you some questions about what has brought you into hospital?"

The General History

Patient details

• Name
• Sex
• Date of birth (age)
• Occupation

For a variety of reasons, from relevance to social aspects of a patient's care to issues surrounding a particular presenting complaint (e.g. weakness), some people also like to ask the patient at the outset whether they are right or left-handed.

Presenting complaint (PC)

This should be a brief description, in the patient's own word, of what has brought the patient to seek medical attention (e.g. "1 hour of worsening central chest pain").

History of presenting complaint (HPC)

This is a detailed background to the presenting complaint. Note any associated symptoms (symptoms separate to the presenting complaint, but related to it - e.g. chest pain "associated with shortness of breath and sweating"). Note any previous episodes or admissions with the same complaint. For pain histories, it can be helpful to use the 'SOCRATES' approach (click on 'socrates' in the column on the right to read more).

Past medical history (PMH)

Note any other medical problems (past and present), as well as previous operations and admissions. In order to ensure that you note some key conditions, use the mnemonic 'MJ THREADS' (Myocardial infarction, Jaundice, Tuberculosis, Hypertension, Rheumatoid arthritis, Epilepsy, Asthma, Diabetes mellitus, Stroke).

Drug history (DH)

List all medication that the patient is currently taking, as well as important drugs that have previously been taken. Note all doses and durations of treatment (e.g. "aspirin (75mg, PO, od) - for past 2 years"). Remember to note over-the-counter medications as well as alternative therapies. Also note any allergies that the patient has (if there are no allergies, "NKDA" or "no known drug allergies" should be written).

Family history (FH)

Note any conditions/illnesses that run in the family. A genogram (family tree) can be useful. It is especially important to note any relevant conditions in immediate family members (parents, siblings, children). It can be helpful to first ask "may I ask if your parents are still alive?" You can then ask if a relative is "fit and well, or has/has had any illnesses?"

Social history (SH)

• Living circumstances: house/bungalow/flat; who else is at home?; emergency procedures if elderly/frail (e.g. alarm, warden-controlled accommodation).
• Activities of daily living (ADL): able to cope? (with washing, dressing, etc.). The Barthel index is a useful questionnaire to assess a patient's ability to cope with the ADLs.
• Exercise/general fitness
• Pets.
• Children.
• Foreign travel
• Diet (e.g. change due to foreign travel?
• Occupation and any exposure to hazardous agents.
• Smoking (number per day, and for how long): 1 pack year = equivalent of smoking 20 cigarettes/day for 1 year (e.g. if someone smokes 10/day for 6 years, then they have a history of 3 pack years).
• Alcohol intake: number of units per week. As a rough guide, an average pint of beer/standard glass of wine = 2-2.5 units, a shot = 1 unit, alcopops = 1.5 units. For a more detailed guide, see the NHS website here: NHS - A guide to alcohol units

Functional or systems enquiry (FE/SE)

This is an overview of the systems not covered during the history of presenting complaint. Some questions to ask, include:

• General: overall health, appetite, weight (body mass index, BMI).
• Cardiovascular: shortness of breath (SOB), chest pain, orthopnoea (SOB on lying flat), postural noctural dyspnoea (PND), palpitations.
• Respiratory: SOB, cough (productive/non-productive, haemoptysis, wheeze).
• Gastrointestinal: nausea/vomiting, diarrhoea/constipation (change of bowel habit).
• Genitourinary: frequency, urgency, nocturia, dysuria.
• Neurological: headache, "fits/faints/funny turns", visual/hearing disturbance.
• Musculoskeletal: joint pain/stiffness.
• Skin: rashes, itching.

Finally...

Thank the patient for their time. Present your findings concisely.

Example presentation

"Mr X is a 40 year old dentist who presented to the emergency department with a 2 hour history of central crushing chest pain. This came on suddenly, and progressively worsened in intensity. It is currently very severe and constant and he describes it as 8/10 in intensity. He described the pain as dull and crushing, as if an elephant had sat on him. The pain radiated to his left shoulder and was associated with sweating and shortness of breath. He has not previously experienced an episode of pain or shortness of breath such as this. Neither has he previously experienced any associated cardiovascular symptoms such as orthopnea, postural nocturnal dyspnoea or palpitations. His past medical history includes type 2 Diabetes mellitus, which is currently diet controlled. He had a nothing else of note in his past medical history. He takes no regular medications and has no known drug allergies. He has smoked 5 cigarettes a day for the past 5 years. He drinks no alcohol. His only regular exercise is a little gardening once a week. He lives with his partner in a flat and is independent for all activities of daily living. There is no significant family history - more specifically, there is no family history of heart disease or diabetes mellitus. There was nothing else of note on functional enquiry, and Mr X is otherwise fit and well. In summary, these findings are consistent with cardiac chest pain, suggestive of a myocardial infarction."