History Taking – Explained

Now that you have read a general template, let’s go through each aspect trying to understand exactly why we ask these specific questions, and what information we hope to gain from them.

Introduction

• Good afternoon, my name is _______ and I am one of the student doctors here. Is it _______(patient’s name)

  
  To begin within, it is essential that you introduce yourself to the patient and clearly explain what level you are i.e. whether you are a medical student, junior doctor, consultant. By doing this, the patient will be able to probably gauge your level of experience and knowledge (not always) and therefore answer accordingly. In addition, many patients enjoy talking to medical students and so this can give the consultation a much more relaxed feel. ​

• I just wanted to ask you some questions about how you are feeling and what has brought you in to see the doctor today, and then I’ll take that information, relay it to the consultant and we can go from there?

  
  It is important to also explain to the patient why you want to take the history. BE HONEST! Is it just for your own learning, or do you plan to discuss the patient’s condition with the consultant later? If the patient understands the reason for a history, they are much more likely to engage with you.​

• Before I start, are you comfortable or would you likely me to get you anything? Do you mind if I take a seat?

  
  Before starting, make sure the patient is comfortable. Many students find themselves asking a few questions, before the patient requests that they need to go to the toilet, or that they haven’t eaten etc. By ensuring that the patient is fully at ease, this increases your chances of taking a detailed, and uninterrupted history. ​

• So, what has brought you in to see the doctor today?

  
  It is important to start the history with an open question. By this we mean a question that allows the patients in their own words to describe what the problem is, rather than a yes or no answer. It may feel odd to do this when we first start taking histories, however from experience, it results in a much more efficient, streamlined and faster consultation in the long run.

  Several clinicians talk about the “Golden Minute” – the aim of this open question is to allow the patient to talk for about a minute. However this is by no means a rule, some will inevitably talk longer whereas for some patients, obtaining a history is like taking blood from a stone. Yet, by keeping as open as you can at the beginning, we can ensure as clinicians we are not putting words into the patients’ mouths and are allowing them to describe what they feel the problem is.

(P) Presenting Complaint

• Summarise patient’s answer and ask first screening question) – Apart from this, have you noticed anything else?
• (Ask second screening question) – Ok, anything else?
• (Ask third screening question) – Before talking more about your [symptom], are there any other symptoms?
• (Last screening question) – Are you sure that there is nothing else?

  
  After your open question and the “golden minute” you are likely to have inundated with a heap of information. One of the simplest, yet most important skills is then to summarise this information back to the patient. This will immediately put them at ease as it demonstrates that you have listened to them. Similarly it will allow you to organise your thoughts and start to form an initial picture in your head after discarding the irrelevant information. Whist it is then extremely tempting to dive in and ask about the symptoms, DO NOT DO THIS!!!

  Patients commonly present with 4 problems (sometimes more). And more often than not, it is the last symptom which may be the most sinister. You will conduct a much smoother, more efficient history if you first are aware of all the symptoms, and only then go through each one in more detail. For example, imagine spending 5 minutes exploring stomach pain in detail only to find out right at the end that the patient’s main symptom is rectal bleeding. In a nutshell, Screen…then scrutinise!!!

• (Once we are sure there are no other questions, we can now address each symptom in turn) – Now I just want to ask some questions about the symptoms you have been feeling? Go through each symptom using OATES or SOCRATES for pain

  
  Once you have fully screened, you now have the license to go through each symptom in turn to understand exactly how the patient is feeling. Many students also start too specific, especially when asking about pain. However, I cannot stress how much information you can obtain by again, starting with an open question and first letting the patient tell you the information – then you can ask specific questions to fill in the gaps. A very simple but useful question is just “Can you tell me a little bit more?”

   

   

  After this, there are several useful acronyms of how to explore a symptom fully. For pain, many students are familiar with the acronym SOCRATES which explores pain in full detail.

  S = Site
  O = Onset
  C = Character
  R = Radiation
  A = Associations
  T = Timing
  E = Exacerbations
  S = Severity

  On the other hand, for other symptoms, students often lose their way and forget to ask important questions. Therefore (much like for pain), the acronym OATES can help provide a useful framework of how to explore each symptom.

  O = Onset (when did it start/what were you doing at the time) 
  A = Associations (is this associated with any other symptoms) 
  T = Timing (It is there all the time/ How often has it happened) 
  E = Exacerbations (Is there anything that makes it better/worse) 
  S = Specifics –> depending on the symptom, you may have to ask certain additional questions (see example histories)

(I) Ideas, Concerns, Expectations

• Ok, you have been feeling these symptoms for some time, do you have any idea of what it could be?
• Are you particularly concerned about anything?

  
  When you first start taking histories, this is the section that most people are tempted to overlook. Why does one need to ask the patient what they think? After all, shouldn’t it be the doctor’s role to work out the diagnosis? However, contrary to student belief, this is actually one of the most important aspects of the history, and more often than not, can reveal the underlying diagnosis. The best way to explain the importance of ICE is with an analogy.

  Let us imagine that in a small village, 100 people get a moderate stomach ache. Out of those 50 will choose to do nothing and try and wait it out. 25 may take some indigestion tablets and get some respite. 10 may look online and self-diagnose IBS and try to be more careful about what they eat. Another 10 may have had this stomach ache before and know that it will subside in a day or so. But 5 choose to visit the GP surgery. Hence, we must question – Why have these 5 patients chosen to visit the GP surgery, compared to the other 95 who decided to wait it out.

  And this is the value of the ICE aspect. This gives us an insight into what exactly the patient is thinking. Many times, even though the symptoms are not severe, patients will present as their is a strong family history of stomach problems, or the patient’s relative/friend was diagnosed with bowel cancer, which is really concerning the patient. And no matter how trivial the symptoms are, there is that deep fear that they also have something sinister. Without asking the ideas and concerns, you will not be able to develop a deeper and more honest rapport with the patient.

• What were you hoping to get out of the visit today?

  
  Many people think that the role of a doctor is to simply cure patients. However, I’m sure we are all aware that this is not always possible – even patients. Therefore, it is vital to ask the patient what they are expecting from the consultation. If they are very worried about a cancer diagnosis for example and came in seeking a blood test, no matter how much you may reassure them, they will not be satisfied until they have definitive proof that they do not have cancer.

  Similarly, if a patient is simply looking for reassurance, there may not be the need to do additional tests, and simply spending 5 minutes longer talking to the patient will make a huge difference. Additionally, by understanding what the patient wants, it sets a purpose/goal which underpins any further questions you may ask – and so the patient is likely to be much more receptive and engaged if they feel they you are helping them achieve what they want.

(S) Systems Review

• (In response to them telling you their expectation from today’s visit) Ok, in order to do that, first I would like to ask you a few more specific questions just to get a more accurate picture of why you might be experiencing these symptoms.

Whilst it might not jump out to you initially, I feel that this is the most important section of the history. Patients are unlikely to tell you every symptoms they are experiencing – it is your role as a doctor to go link the symptoms using your knowledge and fill in the missing gaps. Similarly, you must screen for red flag symptoms – if any of these are positive this should alert you that something sinister might be going on which you really really do not want to miss.

Specific Systems Review (Ask Specific Questions about that system)

This section really differentiates the doctors who know their medical conditions inside out, to those who have just memorised a history taking script. Let us imagine a patient presents with a headache – there are several systems which could cause this. For example it could be neurological (stroke), vascular (bleeds), infective or a simple migraine. Therefore we need to ask questions relating to these systems in order to narrow down and understand exactly what is causing the headache. To make it easier, the specific systems review is included for each of the example histories – but do not worry, as you learn the course, this will make more sense to you.

General Systems Review: (Ask general questions to rule out red flags):

The general systems review is a crucial part of any consultation. Luckily for you, this is fairly standardised across most histories and can be learnt with a simple mnemonic. This screens for red flag symptoms, which if positive should prompt urgent review. To remember the following questions, remember :

“Fat Gorillas Will Always Be Wanting To Try Nice Roast Potatoes” Fat = Fever –> Have you got a fever?
Gorillas = Glands –> Have you got any swollen glands or lumps?
Will = Weight –> Have you experienced any weight loss?
Always = Appetite –> Have you noticed any change in your appetite?
Be = Bowels –> Any changes in your bowel movements?
Willing = Water works –> Are your water works all ok?
To = Tired –> Are you more tired than usual?
Try = Travel –> Have you travelled anywhere recently?
Nice = Night sweats –> Do you ever wake up in the night drenched in sweat?
Roast = Rash –> Have you developed a rash?
(Potatoes = Pill –> Are you on the pill/could you be pregnant?)

For many conditions, this might seem like overkill. Therefore, when you are first starting out, it would be prudent to ask all the questions, and then as you develop more experience you can miss out a couple of these questions if you are sure that they are irrelevant. But it is better to be safe than sorry, especially early in your medical career.

(P) Past Medical History

• And now, about your health in general, have you ever seen your doctor about something like this before?

  
  It is essential to ask whether patients have already seen a doctor about their symptoms. For patients, especially those with chronic conditions, it is likely that they will have been in and out of hospital/GP several times and become experts in their condition. Therefore, they will be able to provide a whole timeline of events right from the first presentation and explain how their disease has progressed. Alternatively, if this is a first presentation, it will enable you to ask more questions to the patient as you want to be as thorough as possible.

• Do you have any other medical conditions, such as diabetes, blood pressure or asthma?

  
  With any patient, we should be equally interested in any comorbidities that they have. This is vital for several reasons. Firstly, everything in the body is connected. A comorbidity is not only going to affect the symptoms a patient is experiencing, but importantly is something you must take into account when estimating the prognosis, deciding which medications to prescribe (to avoid contraindications) and give you and overall sense of the general health of the patient. In addition, several conditions increase the chance of developing further complications down the line – for example, up to 80% of people with PBC also have ulcerative colitis.

  It is worth stating the three conditions in the question as these are 3 of the most common underlying medical conditions. Furthermore, patients who have very well controlled asthma or blood pressure often forget to state that they have these conditions, as it has become so ingrained in their life they (almost) consider it “normal” – hence a gentle reminder is invaluable.

• Have you ever had any surgeries?
• Have you ever been admitted into hospital before?

  
  For the same reasons as before, obtaining a surgical history is just as important as a medical history and should not be overlooked.

 (F) Family History

• Is there any incidence of [patient’s condition type] problems in your family?

  
  After the past medical history, asking about the family is a natural and smooth progression. To open, ask whether there is any incidence of that type of condition within the family – this is very important for heart conditions, cancers as some of these may have a strong genetic component which is essential to identify. If the patient answers yes to this question, it is then important to find out when they were diagnosed. A diagnosis of breast cancer at an age of 25 is much more significant than one at 80 years old, as it more likely to be due to a gene mutation which can be passed down through the generations.

  Many patients get confused by the word “family” – they might tell you that their second cousin once removed had diabetes, and their uncle high blood pressure. Therefore, as a rule of thumb, it is worth specifying to the patient that we are primarily interested in first degree relatives (siblings, parents, children) and at max grandparents. Beyond this, it is safer to assume that other relatives will have less of a genetic influence on the patient.

• Are there any other conditions which run in your family?
  
  Whilst this may not seem like a vital question to ask, it is still important to determine whether there is a high prevalence of a certain disease in the family. This is because, as discussed earlier, we are equally as interested in finding out about all the patient’s actual (and possible) comorbidities as this will influence our care package plan for the patient. In addition, a patient may reveal a condition which you as the clinician may not have considered before as a possible differential – this emphasises the need to keep an open mind as this may explain the symptoms better than your initial differentials.

(D) Drug History

• Are you currently taking any prescribed medication?

   

  Asking about medication is important on two levels. Firstly, some (if not all) of the patient’s problems may be due to a side effect of their medication. This is often the case if the patient has recently started new medication, and so the dose will have to be carefully monitored initially. Secondly, patients often forget to tell you about their medical conditions, no matter how many times you ask. However, if you know your pharmacology well, you will be able to work out any possible underlying conditions by the medication that they are on.

  For example, a patient taking an ACE-inhibitor and a dihydropyridine is more than likely have hypertension which (trust me) they will very often forget to tell you. It may be difficult to obtain a drug history. Whilst some patients may hand you a a list of all their medication, many will not know the names of the medication or even what it is used for, simply remembering medicines by the colours e.g. “I take the blue ones in the morning.” In this case, do not panic. You can always ask a relative if they are also present, or check up the medication in the notes if they are available.

   

• Do you take anything else, over the counter?

  
  Remember, not all medicines are prescribed and many are available over the counter, so do not forget to ask about this. Similarly, patients may take herbal or homeopathic remedies. Whilst you would not be expected to know about all of these as a student, it would be prudent to take note and relay this information to your senior, as they likely might have encountered some common herbal remedies before.

• Do you have any allergies?

  
  This without doubt is a vital question to ask. The last thing we would want to do as a doctor is work out the diagnosis, and start treating the patient only to cause an allergic reaction, which (in the worst case scenario) can be fatal. Therefore, better to be safe than sorry – this is a question which you cannot forget to ask.

(S) Social History

• (Work) And now, a little but more about yourself in general, do you work at the moment? What do you do?
• (Home) Do you live with any family or friends? Are you married? Do you have any children?
• (Independence) Would you say that you are fairly independent?

  
  (Part A) When we take a history, we have to remember that patients are also real people with lives, jobs, families etc. They are not just physical manifestations of disease that we read about in the textbook. No two patients will be the same – even if they have the same presenting complaint and past medical history, one might live in an affluent area and have greater access to healthcare, where another might live by themselves with very little support. Since a patient’s illness depends on an interaction between their physical disease and their environment it is crucial to explore a patient’s job, living situation and general level of independence.

  In addition, many diseases may be linked to a patient’s occupation. For example, heavy lifting and musculoskeletal conditions (arthritis), mining and respiratory conditions, asbestos exposure and cancer. We do not want to order several expensive tests and further investigations only to discover the root cause of the problem is at the patient’s workplace. In addition, talking about a patient’s job or family is a great method of establishing a rapport. Hospitals can be boring, and many of our patients might live alone – and so the rare opportunity to share your life stories with a budding medical student puts patients in a relaxed mood and allows you to develop a stronger doctor-patient relationship.

And now these are some questions that we ask everyone:

• Do you smoke? (Have you ever smoked? / When did you start? / How many a day?)
• Do you drink? (How much a week? And for how long?)​
• Is there any recreational drug use?

  
  (Part B) The next 3 questions are quite personal and so, it is advisable to ask them at the end once you have established a rapport with the patient. However, explaining to the patient that these are questions which you have to ask everyone will help lower their guard and reassure them that you are not suspecting/alleging them of being nicotine/alcohol addicts. Nevertheless, these questions are still vitally important – almost every disease can be linked with smoking, drinking or drug use in some way. The important thing to realise is that these are not just yes or no questions.

  If a patient replies yes to any of these questions, you should then try to quantify exactly how much the patient drinks/smokes and for how long – they will dose dependently increase the risk of many diseases. Similarly, if a patient replies no, it is vital to ask whether they have ever smoke/drunk. Frustratingly, many patients (especially those admitted into hospital) will say they don’t smoke only to reveal that they stopped only 2 days ago and have a 20 year pack history.

Conclusion

• Ok, just to recap to make sure I haven’t missed anything (quick summary.)
• Thank you very much, I’ll relay this information to the consultant and then we can go from there. Do you have any questions?
  
  The aim of the conclusion is to bring the consultation to a fitting end. It is sensible here to provide a quick summary of the main salient findings of the history, and then confirm with the patient whether you have missed anything important. It can be frustrating, but some patients will not disclose information to you until they feel very comfortable with you, which can be at the very very end. However, this is just part of the process, and by asking one more time, you ensure that you are giving the patient as much opportunity to share their information. It is very important to thank the patient at the end, especially if you are a medical student. You may not have appreciated it at the moment, but this history is all invaluable experience which not only will aide your communication skills with patients, but also help you to understand the patient’s condition better. ‌

  Hopefully, this gives you a deeper insight and helps you to understand how we can take a full clinical history using the acronym PISP-FDS! I’m sure that many of you might still have questions – after all, this is just a template and there are many circumstances where we have to deviate or slightly amend our model. Read on to the FAQ section to find out about these situations and how we can get round them to still take a full history.