1. Introduction to
medical history taking

2. Before you start to take any
history…..
1. Wash hands
2. Establish initial rapport
• Greet patient and obtain patient’s name and age
• Introduce self and clarify role
• Explain nature of interview, seek consent
• Demonstrate interest and respect, attend to patient’s
physical comfort
(taken from the Calgary-Cambridge Guide)

3. • What is a history?
A patient narrative facilitated by the
doctor or medical student
A dialogue
Information given by the patient and
gathered by the interviewer using
their generic communication skills
Recorded (not taken)in a standard
way

4. • Why is information recorded in a
standard way?
As a learner, to check you don’t miss
anything!
As a clinician - to facilitate diagnosis
- to communicate
information
effectively with your
colleagues

5. Basic Structure of Any Medical
History
• PC Presenting complaint
• HPC History of Presenting Complaint
• PMH Past Medical History
• DH/Med Drug History
• FH Family History
• SH Social History
• SE Systems Enquiry
• ICE Ideas, concerns, expectations

6. Basic Structure of Any Medical
History
• PC Presenting complaint
Brief description of the presenting problem or
symptom (may be verbatim)
• HPC History of Presenting Complaint
- time scale
- describe and explore presenting symptoms
- review of all symptoms of relevant body system
- may include important positives and negatives from
PMH, FH, SH
- may include the patient’s perspective

7. • PMHPast Medical History
- relevant to presenting complaint
- specific major operations
- specific major illnesses
- general health
• Drug history
- current prescribed medication
- over the counter (OTC)
- homeopathic or health supplements (CAM)
- specific medications for the presenting body system

8. • Allergies
- NKDA No known drug allergies
- Allergies Drug and reaction
• FH Family History
• SH Social History
- Occupation
- Household and housing
- Lifestyle factors including alcohol, smoking, exercise
-Activities of daily living

9. • ICE Ideas, concerns, expectations
The patient’s view of their illness.
Feelings, thoughts, impact.
(Will be covered more in PPD next term)
• SE Systemic enquiry (or Review of systems)
A check list covering key symptoms within all major body systems
(covered in Stage 2 and Phase 2)
• Summary (covered in Stage 2)

10. Further reading on History
Taking read about this aspect of communication in more
If you want to
detail, any of the following would be a good starting point:
• Silverman, Kurtz and Draper. Skills for communicating with
patients, Chapter 3., pp 70-85 (Exploration of problems)
• Lloyd and Bor. Communication skills for medicine, Chapter 2.,
(Basic communication skills)
• Myerscough and Ford. Talking with patients Chapter 3,
(Conducting an interview)
• Two papers on history taking by DR Nayankumar Shah from
studentBMJ in September and October 2005 (
http://www.studentbmj.com/issues/05/09/education/314.php
and
http://www.studentbmj.com/issues/05/10/education/358.php
)
• Macleod`s Clinical Examination, 12th ed, Churchill Livingstone.