care to anyone with whom you have a close personal relationship.

Finally, remember that, to be fit to take care of patients, you

must first take care of yourself. If you think you have a medical

condition that you could pass on to patients, or if your judgement

or performance could be affected by a condition or its treatment,

consult your general practitioner. Examples might include serious

communicable disease, significant psychiatric disease, or drug

or alcohol addiction.

Fundamentally, patients want doctors who:

• are knowledgeable

• respect people, healthy or ill, regardless of who they are

• support patients and their loved ones when and where

needed

• always ask courteous questions, let people talk and listen

to them carefully

• promote health, as well as treat disease

• give unbiased advice and assess each situation carefully

• use evidence as a tool, not as a determinant of practice

• let people participate actively in all decisions related to

their health and healthcare

• humbly accept death as an important part of life, and

help people make the best possible choices when death

is close

• work cooperatively with other members of the

healthcare team

• are advocates for their patients, as well as mentors for

other health professionals, and are ready to learn from

others, regardless of their age, role or status.

One way to reconcile these expectations with your inexperience

and incomplete knowledge or skills is to put yourself in the

situation of the patient and/or relatives. Consider how you would

wish to be cared for in the patient’s situation, acknowledging that

you are different and your preferences may not be the same.

Most clinicians approach and care for patients differently once

they have had personal experience as a patient or as a relative

of a patient. Doctors, nurses and everyone involved in caring for

patients can have profound influences on how patients experience

illness and their sense of dignity. When you are dealing with

patients, always consider your:

• A: attitude – How would I feel in this patient’s situation?

• 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

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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

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