Medical History Taking Summary

General Framework for Taking History

• Follow a general framework for taking history to gain good marks in history stations
• This framework is also useful for presenting history in a clear and concise manner

Procedure Steps

• Introduce yourself, identify your patient, and gain consent to speak with them
• Ask permission to take notes if needed
• Steps to follow:
  • Presenting Complaint (PC)
  • History of Presenting Complaint (HPC)
  • Past Medical History (PMH)
  • Summary of History
  • Patient Questions / Feedback

Presenting Complaint (PC)

• Identify the patient's main complaint (e.g., chest pain)

History of Presenting Complaint (HPC)

• Gain detailed information about the complaint using the SOCRATES acronym
• SOCRATES stands for:
  • Site: Where exactly is the pain?
  • Onset: When did it start, was it constant/intermittent, gradual/ sudden?
  • Character: What is the pain like (e.g., sharp, burning, tight)?
  • Radiation: Does it radiate/move anywhere?
  • Associations: Is there anything else associated with the pain (e.g., sweating, vomiting)?
  • Time course: Does it follow any time pattern, how long did it last?
  • Exacerbating / relieving factors: Does anything make it better or worse?
  • Severity: How severe is the pain (consider using the 1-10 scale)?

Past Medical History (PMH)

• Gather information about a patient's other medical problems (if any)
• Cover the main systems:
  • CVS
  • Respiratory
  • GI
  • Neurology
  • Genitourinary/renal
  • Musculoskeletal
  • Psychiatry

Summary of History

• Review the patient's history and repeat back important points
• Use the ICE acronym to address:
  • Ideas: What the patient thinks is wrong with them
  • Concerns: What the patient is worried about
  • Expectations: What the patient hopes to achieve from the consultation

Patient Questions / Feedback

• Answer patient questions or provide information when possible
• If unsure, say you will ask seniors or provide further information later

Family History

• A patient's family medical history can play a significant role in their health
• Document genetic health concerns, hereditary diseases, and cancers

Treatment History

• A patient's treatment history is a vital part of their medical record
• Include:
  • Chief complaints
  • History of illness
  • Vital signs
  • Physical examination
  • Surgical history
  • Obstetric history
  • Medical allergies
  • Family history
  • Immunization history
  • Habits (e.g., diet, alcohol intake, exercise, drug use/abuse, smoking)

Medical Directives

• Medical directives outline patient directions for medical care if they cannot communicate
• Include:
  • DNR (Do Not Resuscitate order)
  • Will and other medical directives