• B: behaviour – Always treat patients with kindness and

respect.

• C: compassion – Recognise the human story that

accompanies each illness.

• D: dialogue – Listen to and acknowledge the patient.

Confidentiality and consent

As a student and as a healthcare professional, you will be

given private and intimate information about patients and their

families. This information is confidential, even after a patient’s

death. This is a general rule, although its legal application varies

This page intentionally left blank

2

2

General aspects of

history taking

J Alastair Innes

Karen Fairhurst

Anna R Dover

The importance of a clear history 10

Gathering information 10

Beginning the history 10

The history of the presenting symptoms 11

Past medical history 13

Drug history 13

Family history 14

Social history and lifestyle 14

Systematic enquiry 16

Closing the interview 16

Difficult situations 16

Patients with communication difficulties 16

Patients with cognitive difficulties 16

Sensitive situations 16

Emotional or angry patients 16

10 • General aspects of history taking

The way you ask a question is important:

• Open questions are general invitations to talk that avoid

anticipating particular answers: for example, ‘What was

the first thing you noticed when you became ill?’ or ‘Can

you tell me more about that?’

• Closed questions seek specific information and are used

for clarification: for example, ‘Have you had a cough

today?’ or ‘Did you notice any blood in your bowel

motions?’

Both types of question have their place, and normally clinicians

move gradually from open to closed questions as the interview

progresses.

The following history illustrates the mix of question styles

needed to elucidate a clear story:

When did you first feel unwell, and what did you

feel? (Open questioning)

Well, I’ve been getting this funny feeling in my chest

over the last few months. It’s been getting worse and

worse but it was really awful this morning. My husband

called 999. The ambulance came and the nurse said I

was having a heart attack. It was really scary.

When you say a ‘funny feeling’, can you tell me

more about what it felt like? (Open questioning,

steering away from events and opinions back to

symptoms)

Well, it was here, across my chest. It was sort of tight,

like something heavy sitting on my chest.

And did it go anywhere else? (Open but clarifying)

Well, maybe up here in my neck.

What were you doing when it came on? (Clarifying

precipitating event)

Just sitting in the kitchen, finishing my breakfast.

How long was the tightness there? (Closed)

About an hour altogether.

So, you felt a tightness in your chest this morning

that went on for about an hour and you also felt it

in your neck? (Reflection)

Yes that’s right.

Did you feel anything else at the same time?

(Open, not overlooking secondary symptoms)

I felt a bit sick and sweaty.

Showing empathy when taking a history

Being empathic helps your relationship with patients and improves

their health outcomes (p. 5). Try to see the problem from their

point of view and convey that to them in your questions.

Consider a young teacher who has recently had disfiguring

facial surgery to remove a benign tumour from her upper jaw.

Her wound has healed but she has a drooping lower eyelid and

facial swelling. She returns to work. Imagine how you would feel

in this situation. Express empathy through questions that show

you can relate to your patient’s experience.

So, it’s 3 weeks since your operation. How is your

recovery going?

OK, but I still have to put drops in my eye.

And what about the swelling under your eye?

That gets worse during the day, and sometimes by the

afternoon I can’t see that well.

The importance of a clear history

Understanding the patient’s experience of illness by taking a

history is central to the practice of all branches of medicine.

The process requires patience, care and understanding to yield

the key information leading to correct diagnosis and treatment.

In a perfect situation a calm, articulate patient would clearly

describe the sequence and nature of their symptoms in the order

of their occurrence, understanding and answering supplementary

questions where required to add detail and certainty. In reality a

multitude of factors may complicate this encounter and confound

the clear communication of information. This chapter is a guide

to facilitating the taking of a clear history. Information on specific

symptoms and presentations is covered in the relevant system

chapters.

Gathering information

Beginning the history

Preparation

Read your patient’s past records, if they are available, along with

any referral or transfer correspondence before starting.

Allowing sufficient time

Consultation length varies. In UK general practice the average

time available is 12 minutes. This is usually adequate, provided the

doctor knows the patient and the family and social background.

In hospital, around 10 minutes is commonly allowed for returning

outpatients, although this is challenging for new or temporary

staff unfamiliar with the patient. For new and complex problems

a full consultation may take 30 minutes or more. For students,

time spent with patients learning and practising history taking

is highly valuable, but patients appreciate advance discussion

of the time students need.

Starting your consultation

Introduce yourself and anyone who is with you, shaking hands

if appropriate. Confirm the patient’s name and how they prefer

to be addressed. If you are a student, inform patients; they are

usually eager to help. Write down facts that are easily forgotten,

such as blood pressure or family tree, but remember that writing

notes must not interfere with the consultation.

Using different styles of question

Begin with open questions such as ‘How can I help you

today?’ or ‘What has brought you along to see me today?’

Listen actively and encourage the patient to talk by looking

interested and making encouraging comments, such as ‘Tell me

a bit more.’ Always give the impression that you have plenty of

time. Allow patients to tell their story in their own words, ideally

without interruption. You may occasionally need to interject to

guide the patient gently back to describing the symptoms, as

anxious patients commonly focus on relating the events or the

reactions and opinions of others surrounding an episode of illness

rather than what they were feeling. While avoiding unnecessary

repetition, it may be helpful occasionally to tell patients what

you think they have said and ask if your interpretation is correct

(reflection).

Gathering information • 11

2

increases the likelihood of lung cancer and chronic obstructive

pulmonary disease (COPD). Chest pain does not exclude COPD

since he could have pulled a muscle on coughing, but the pain

may also be pleuritic from infection or thromboembolism. In

turn, infection could be caused by obstruction of an airway by

lung cancer. Haemoptysis lasting 2 months greatly increases the

chance of lung cancer. If the patient also has weight loss, the

positive predictive value of all these answers is very high for lung

cancer. This will focus your examination and investigation plan.

What was the first thing you noticed wrong when

you became ill? (Open question)

I’ve had a cough that I just can’t get rid of. It started

after I’d had flu about 2 months ago. I thought it would

get better but it hasn’t and it’s driving me mad.

Could you please tell me more about the cough?

(Open question)

Well, it’s bad all the time. I cough and cough, and

bring up some phlegm. It keeps waking me at night so

I feel rough the next day. Sometimes I get pains in my

chest because I’ve been coughing so much.

Already you have noted ‘Cough’, ‘Phlegm’ and

‘Chest pain’ as headings for your history. Follow up

with key questions to clarify each.

Cough: Are you coughing to try to clear something

from your chest or does it come without warning?

(Closed question, clarifying)

Oh, I can’t stop it, even when I’m asleep it comes.

Does it feel as if it starts in your throat or your

chest? Can you point to where you feel it first?

It’s like a tickle here (points to upper sternum).

Phlegm: What colour is the phlegm? (Closed

question, focusing on the symptom)

Clear.

And how does that feel at work?

Well, it’s really difficult. You know, with the kids and

everything. It’s all a bit awkward.

I can understand that that must feel pretty

uncomfortable and awkward. How do you cope?

Are there are any other areas that are awkward for

you, maybe in other aspects of your life, like the

social side?

The history of the presenting symptoms

Using these questioning tools and an empathic approach, you

are now ready to move to the substance of the history.

Ask the patient to think back to the start of their illness and

describe what they felt and how it progressed. Begin with some

open questions to get your patient talking about the symptoms,

gently steering them back to this topic if they stray into describing

events or the reactions or opinions of others. As they talk, pick

out the two or three main symptoms they are describing (such

as pain, cough and shivers); these are the essence of the history

of the presenting symptoms. It may help to jot these down as

single words, leaving space for associated clarifications by closed

questioning as the history progresses.

Experienced clinicians make a diagnosis by recognising

patterns of symptoms (p. 362). With experience, you will refine

your questions according to the presenting symptoms, using

a mental list of possible diagnoses (a differential diagnosis) to

guide you. Clarify exactly what patients mean by any specific

term they use (such as catarrh, fits or blackouts); common terms

can mean different things to different patients and professionals

(Box 2.1). Each answer increases or decreases the probability

of a particular diagnosis and excludes others.

In the following example, the patient is a 65-year-old male

smoker. His age and smoking status increase the probability

of certain diagnoses related to smoking. A cough for 2 months

2.1 Examples of terms used by patients that should be clarified

Patient’s term Common underlying problems Useful distinguishing features

Allergy True allergy (immunoglobulin E-mediated reaction) Visible rash or swelling, rapid onset

Intolerance of food or drug, often with nausea or

other gastrointestinal upset

Predominantly gastrointestinal symptoms

Indigestion Acid reflux with oesophagitis Retrosternal burning, acid taste

Abdominal pain due to:

Peptic ulcer

Gastritis

Cholecystitis

Pancreatitis

Site and nature of discomfort:

Epigastric, relieved by eating

Epigastric, with vomiting

Right upper quadrant, tender

Epigastric, severe, tender

Arthritis Joint pain Redness or swelling of joints

Muscle pain Muscle tenderness

Immobility due to prior skeletal injury Deformity at site

Catarrh Purulent sputum from bronchitis Cough, yellow or green sputum

Infected sinonasal discharge Yellow or green nasal discharge

Nasal blockage Anosmia, prior nasal injury/polyps

Fits Transient syncope from cardiac disease Witnessed pallor during syncope

Epilepsy Witnessed tonic/clonic movements

Abnormal involuntary movement No loss of consciousness

Dizziness Labyrinthitis Nystagmus, feeling of room spinning, with no other neurological deficit

Syncope from hypotension History of palpitation or cardiac disease, postural element

Cerebrovascular event Sudden onset, with other neurological deficit

12 • General aspects of history taking

Having clarified the presenting symptoms, prompt for any

more associated features, using your initial impression of the

likely pathology (lung cancer or chronic respiratory infection) to

direct relevant questions:

Do you ever feel short of breath with your cough?

A bit.

How has your weight been? (Seeking additional

confirmation of serious pathology)

I’ve lost about a stone since this started.

The questions required at this point will vary according to the

system involved. A summary of useful starting questions for each

system is shown in Box 2.3. Learn to think, as you listen, about

the broad categories of disease that may present and how these

relate to the history, particularly in relation to the onset and rate

of progression of symptoms (Box 2.4).

To complete the history of presenting symptoms, make an

initial assessment of how the illness is impacting on the life of

your patient. For example, breathlessness on heavy exertion

may prevent a 40-year-old builder from working but would have

much less impact on a sedentary retired person. ‘Can you tell

me how far you can walk on a good day?’ is a question that

can help to clarify the normal level of functioning, and ‘How

has this changed since you have been unwell?’ can reveal

disease impact. Ask if the person undertakes sports or regular

exercise, and if they have modified these activities because

of illness.

Have you ever coughed up any blood? (Closed

question)

Yes, sometimes.

When did it first appear and how often does it

come? (Closed questions)

Oh, most days. I’ve noticed it for over a month.

How much? (Closed question, clarifying the

symptom)

Just streaks.

Is it pure blood or mixed with yellow or green

phlegm?

Just streaks of blood in clear phlegm.

Chest pain: Can you tell me about the chest pains?

(Open question)

Well, they’re here on my side (points) when I cough.

Does anything else bring on the pains? (Open,

clarifying the symptom)

Taking a deep breath, and it really hurts when I cough

or sneeze.

Pain is a very important symptom common to many areas of

practice. A general scheme for the detailed characterisation of

pain is outlined in Box 2.2.

2.2 Characteristics of pain (SOCRATES)

Site

• Somatic pain, often well localised, e.g. sprained ankle

• Visceral pain, more diffuse, e.g. angina pectoris

Onset

• Speed of onset and any associated circumstances

Character

• Described by adjectives, e.g. sharp/dull, burning/tingling, boring/

stabbing, crushing/tugging, preferably using the patient’s own

description rather than offering suggestions

Radiation

• Through local extension

• Referred by a shared neuronal pathway to a distant unaffected site, e.g.

diaphragmatic pain at the shoulder tip via the phrenic nerve (C3, C4)

Associated symptoms

• Visual aura accompanying migraine with aura

• Numbness in the leg with back pain suggesting nerve root irritation

Timing (duration, course, pattern)

• Since onset

• Episodic or continuous:

• If episodic, duration and frequency of attacks

• If continuous, any changes in severity

Exacerbating and relieving factors

• Circumstances in which pain is provoked or exacerbated, e.g. eating

• Specific activities or postures, and any avoidance measures that

have been taken to prevent onset

• Effects of specific activities or postures, including effects of

medication and alternative medical approaches

Severity

• Difficult to assess, as so subjective

• Sometimes helpful to compare with other common pains, e.g.

toothache

• Variation by day or night, during the week or month, e.g. relating to

the menstrual cycle

2.3 Questions to ask about common symptoms

System Question

Cardiovascular Do you ever have chest pain or tightness?

Do you ever wake up during the night feeling

short of breath?

Have you ever noticed your heart racing or

thumping?

Respiratory Are you ever short of breath?

Have you had a cough? If so, do you cough

anything up?

What colour is your phlegm?

Have you ever coughed up blood?

Gastrointestinal Are you troubled by indigestion or heartburn?

Have you noticed any change in your bowel habit

recently?

Have you ever seen any blood or slime in your

stools?

Genitourinary Do you ever have pain or difficulty passing urine?

Do you have to get up at night to pass urine? If

so, how often?

Have you noticed any dribbling at the end of

passing urine?

Have your periods been quite regular?

Musculoskeletal Do you have any pain, stiffness or swelling in

your joints?

Do you have any difficulty walking or dressing?

Endocrine Do you tend to feel the heat or cold more than

you used to?

Have you been feeling thirstier or drinking more

than usual?

Neurological Have you ever had any fits, faints or blackouts?

Have you noticed any numbness, weakness or

clumsiness in your arms or legs?

Gathering information • 13