Table of Contents
- Wash your hands
- Introduce yourself
- Permission or consent for asking history and taking notes
- Eye contact
- Remove barriers (try not to position desk or bed between you and patient) and sit at the same level as patient
Mnemonic: DNA SORAN
- Next of kin
Presenting Complaint (PC)
A good opening question might be “What seems to be the problem today?”.
It must be recorded:
- In patient’s own words
- In reverse chronological order (i.e. most recent symptoms first)
It can be recorded as:
- Symptom 1 X Duration
- Symptom 2 X Duration
- Symptom 3 X Duration
History of Presenting Complaint (HPC)
Start in the order of PC, i.e. reverse chronological order.
The HPC should basically assess following features of the presenting complaint.
- Quality: what, where and how
- Quantity: how much and impact on life
- Timeline: duration, onset, progression, offset
- Associated features, risk factors and complications
Use the OPERATES+ mnemonic for each presenting complaint.
- Onset: When did the problem start?
- Progress: Has it always been the same?
- Exacerbating factors: Is there anything that makes it worse?
- Relieving factors: Is there anything that makes it better?
- Associated symptoms: When you get this problem, do you notice any other symptoms?
- Timing: Is there any time of day that you notice this problem more? How long does each episode last?
- Episodes of recovery/ever before: Have you had this problem before? How often do you feel like this?
- Severity: How bad is it?
- + (Function): Does it prevent you from doing particular activities?
Use the SOCRATES mnemonic for pain history.
- Site: Where is the pain?
- Onset: Where did the pain start?
- Character: Describe the pain, e.g. is it aching, shooting, stabbing or dull?
- Radiation: Does the pain move to anywhere else in the body?
- Associated symptoms: Have you had any symptoms other than the pain?
- Timing: Pattern of pain (including time of day, frequency), Duration of pain, Is it constant or does it come and go?
- Exacerbating or relieving factors: Have you noticed anything that makes the pain better or worse?
- Does the pain interfere with what you are doing?
- Does it keep you awake?
- If 0-10 is a scale of pain, with 0 as no pain and 10 as the worse pain that you can imagine, what score would you give this pain?
Past Medical and Surgical History (PMH and PSH)
Start by asking an open question such as:
- Have you had any serious illness in the past?
- Have you had any operations? and/or Have you ever had an anesthetic?
PMH: Mnemonic – JAM THREADS
- Anemia and other hematological conditions
- TB, Thyroid disorder
- Hypertension and heart diseases
- Diabetes, DVT/PE
PSH: Past and Pending surgeries (open/laparoscopy/endoscopy/endovascular) and Complications
Women: Last menstrual period (LMP), Vaginal bleeding or discharge, Pregnancies, Deliveries
If there are any of these diseases, you must establish details of each disease such as level of control, complications, follow-up and the level of patient’s education regarding the disease. Example –
- Myocardial infarction – Diagnosed in 2016. Underwent percutaneous coronary intervention (PCI). Had two stents placed. Seen in cardiology clinic yearly.
- Cholelithiasis – Diagnosed in 2014. Underwent a cholecystectomy (gallbladder removal) in 2015. No further issues.
Drug History (DH)
Start with questions like:
- ‘Do you have your medications with you?’ or ‘Do you have your prescription?’
- ‘Do you have any allergies?’ or ‘Have you ever had a reaction to a medicine that you have taken?’
Use the mnemonic: DRUGS
- Doctor prescribed (including anticoagulants and antiplatelet drugs)
- Recreational (including anabolic steroids, illicit drugs)
- User (over the counter purchases, alternative/traditional medicines)
- Gynecological (contraceptives, HRTs)
- Sensitivities (exact nature of response and allergies)
For each drug, following points must be recorded:
Immunization: This should be recorded for relevant cases – children, elderly patients or any patients with chronic conditions.
- Up to date immunizations?
- Flu vaccinations?
Start with questions like ‘Are there any illnesses that run in your family?’ or ‘Has anyone in your family had a similar problem?’
When gathering a family history, you need to find out the condition affected by the relative, the age at which it was diagnosed and the relationship to the patient. A family tree can be used to help represent this information.
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).
- Mother (first-degree relative), lung cancer, diagnosed at 45
- Maternal aunt (second-degree relative), breast cancer, diagnosed 32
- Father (first-degree relative), hypertension, diagnosed 65
- Accomodation: Do you live in a flat or a house? Who do you live with?
- Profession: Are you working? What job do you do?
- Alcohol: How much do you drink each week? or How quickly do you finish a 75 cl sized bottle of whisky? (quantify in units per week)
- Units of alcohol = Alcohol by volume (%) X Volume of alcohol (ml) / 1000
- 1 unit of alcohol = 10 ml of pure alcohol (100%)
- Limits: 21 units/week for male and 14 units/week for female
- Screen for alcohol dependence: ≥2 “yes” out of 4 CAGE questionnaire requires assessment for alcohol dependence –
- Have you ever felt that you needed to Cut down on your drinking?
- Have people Annoyed you by criticizing your drinking?
- Have you ever felt Guilty about drinking?
- Have you ever felt that you needed a drink first thing in the morning (Eye-opener)?
- Smoking and other tobacco products: Do you or have you ever smoked? (quantify in pack-years)
- 20 cigarettes per day for 1 year = 1 pack year
- Exposures: e.g. Asbestos, Birds, Cats, Pollution, etc.
Review of Systems
Start with a statement such as: ‘I am now going to ask you some specific questions’.
3 general questions (to screen malignancy or chronic infections) related to: WAF –
- Weight loss
- Fever or night sweats
Close ended questions based on mnemonic CHAFRUL –
- Chest pain or shortness of breath
- Headaches or visual or hearing problems
- Abdominal pain
- Fits, falls, dizzy spells or funny turns
- Rashes and joint problems
- Urinary or bowel problems (and periods in women)
- Lumps and bumps
Ideas, Concerns and Expectations (ICE)
- Ideas: ‘Do you have any idea about what could be going on?’
- Concerns: ‘Is there anything which is concerning you at the moment?’
- Expectations: ‘Was there anything you were hoping for from our discussion today?’
- Complete your history by reviewing what the patient has told you. Repeat back the important points so that the patient can correct you if there are any misunderstandings or errors.
- Ask if patients have any questions to ask at the end.
- PocketTutor – Clinical Examination
- DrExam Part B MRCS OSCE Revision Guide: Book 2
- Gogalniceanu, P. (n.d.). Surgical history and documentation. Physical Examination for Surgeons, 16–26. doi:10.1017/cbo9781107338562.003