History Taking

Star InactiveStar InactiveStar InactiveStar InactiveStar Inactive
 

Obtaining a patient’s medical history is generally considered the most important step in developing a differential diagnosis. It has been stated that history-taking contributes around 80% towards the diagnosis with many texts relating to an article by Hampton et al. (1975). According to Talley and O’Connor (2013) an comprehensive history will aid in identifying the most appropriate investigations required and in most case lead to the diagnosis. The physical examination and investigations which follow history taking are merely to confirm or refute the differentials.

Using a structured approach to obtain the patient's medical history ensures that no elements are omitted. The following approach is generally recommended by major text book:

Demographics

Obtain:

  • Name, date of birth (age), gender, occupation, marital status
  • GP's name and address
  • Source: history obtained from the patient? relative? carer?
  • Referral source: GP, Emergency Department, Self

The information from the demographics (name, address and date of birth) also confirms the identity of the patient.

Presenting Complaint (PC)
History of Presenting Complaint (HPC)
Systems Review (SR)
Past Medical History (PMH)
Drug History (DH)
Family History (FH)
Social History (SH)
Travel History (TH)
Other Areas
  • Blundell, A., and Harrison, R. (2013) OSCEs at a Glance.West Sussex: Wiley-Blackwell.
  • Hampton, J. R., Harrison, M., Mitchell, J. R., Prichard, J. S., and Seymour, C. (1975) Relative contributions of history-taking, physical examination, and laboratory investigation to diagnosis and management of medical outpatients. British Medical Journal.Vol.2(5969), pp.486-489.
  • Talley, N. J., and O’Connor, S. (2013) Clinical examination: a systematic guide to physical diagnosis.7th ed. Sydney: Churchill Livingstone.