01 / CHAPTER 3
Listen, focus and make a plan
Listen first. Use the history to work out what needs to happen next.
A focused history still needs enough breadth to avoid missing the important problem. Start with the person’s account, find out why they sought help now, and let what you hear guide the next question. In a FRCEM station, make your priorities, reasoning and uncertainty clear.
Read the task and the domains in your candidate instructions. The framework below is a way to organise a consultation; it is not an RCEM checklist or a promise of marks. See RCEM’s station guidance.
Listen
Introduce yourself and your role, confirm identity and check that the person is happy to talk. Attend to pain, privacy and communication needs. Ask an open question and give them time to answer before narrowing the conversation.
“What has brought you in today?” Then, if it is unclear: “What made you decide to seek help now?”
Focus
Establish the sequence, severity and effect on daily life. Ask the relevant questions that would change urgency, the differential diagnosis or the next step. If the history suggests serious illness or deterioration, pause the routine questions and arrange assessment and help.
Use the system questions to fill gaps, not as a list to recite. Select relevant medical, surgical, psychiatric, obstetric and gynaecological history; medicines, allergies, family history and social circumstances. Include over-the-counter medicines and contraception when relevant.
Clarify
Check ambiguous words and dates. Explore the person’s understanding, concerns, expectations and practical priorities. A worry may not be voiced until you ask; it is not something to catch the patient out over.
“What worries you most about this?” “Is there something you hoped we could help with today?”
Ask sensitive questions in private and explain why they matter. Consider support at home, caring responsibilities and safeguarding when relevant. Use an appropriate interpreter or other communication support.
Reason
Compare the information with your working differential. What supports it? What important alternative remains possible? Ask a targeted question to resolve a gap rather than collecting another unrelated system review. Separate what the patient reported from your interpretation, and say when information is missing.
Where the task asks for a discussion with the examiner, explain which findings change your priorities and how you would investigate or reassess. Do not offer a definitive diagnosis simply because the conversation is ending.
Summarise
Give a short account of the problem, time course, important positives and relevant negatives that you actually established. Include the person’s main concern and any uncertainty that affects the plan. Check that you have understood.
“Let me summarise what you’ve told me. Please correct anything I’ve missed.”
Plan
Explain the next useful step in plain language: examination, observations, investigation, treatment, specialist advice or reassessment, as appropriate. Discuss options and check understanding. If discharge is appropriate, agree follow-up and specific advice on when, where and how to seek help. Address relevant issues such as fitness to drive using current guidance.
“This is what I think may be happening, and this is what I would like to check next. How does that sound to you?”
Invite remaining questions and thank the patient. A history station may stop before examination or treatment; describe only what the task and available information support.
Understanding the patient’s concerns
These examples show why the same presenting complaint may mean different things to different people. Explore concerns alongside the clinical assessment.
| Presenting complaint | |
|---|---|
| Swollen testicle | Fear of malignancy |
| A child who may have taken paracetamol | A parent’s friend died following an overdose |
| Headache | A relative died of a subarachnoid haemorrhage |
| Ankle injury | A fracture was missed on a previous visit |
These habits are consistent with the GMC’s guidance on listening, information and shared decisions and the RCEM curriculum.
02 / CHAPTER 3
Practise a focused history
Work with a colleague. One takes the history; the other plays the patient and gives feedback afterwards. Choose a presenting problem and a fictional or properly anonymised case before starting. The candidate should know only the information that would be available at the start of a consultation.
Before the first attempt: agree the patient’s opening account, symptom timeline, relevant background and one concern or priority. Use a case you can both discuss accurately. Keep unsupplied details unknown; do not reward invented normal findings.
Try the consultation without reading the prompts. For exam rehearsal, RCEM currently allows eight minutes per station; allow separate time for feedback and a second attempt.
Give feedback on the conversation
- Did the opening give the patient room to explain why they came?
- Which questions changed the assessment or plan? Which added little?
- Were unvoiced concerns and practical priorities heard and addressed?
- Did the summary distinguish known facts, interpretation and uncertainty?
- Was the next step clear to the patient?
Name one thing to keep and one thing to change. Repeat the part that needs work, then swap roles. When you next take a history on shift, ask a supervising colleague to observe that same part.
For example, if the opening became a long background checklist, replay the first minute starting with the presenting problem. If the ending was vague, replay the summary and explain one specific next step.
03 / CHAPTER 3
Pain: SOCRATES
SOCRATES is a memory aid for exploring pain. Let the patient describe the problem first, then use relevant prompts to fill the gaps.
| Prompt | Explore |
|---|---|
| Site | Where is the pain? Localised or generalised? |
| Onset | When did it start? Sudden or gradual? |
| Character | What does it feel like: sharp, aching, burning? |
| Radiation | Does it spread anywhere? |
| Associated symptoms | What else happens with it, such as nausea, vomiting or systemic symptoms? |
| Timing | Constant or intermittent? Duration, pattern and progression? |
| Exacerbating and relieving factors | What makes it worse or better? |
| Severity | How severe is it, and how does it affect function? Is this the worst it has been? |
04 / CHAPTER 3
System questions
Choose the questions that fit the presenting problem. These lists support recall; they are not exhaustive histories or diagnostic rules. Try recalling the relevant questions before reading the prompts.
Generic
- Weight loss
- Fevers; sweats
- Tiredness
- Lethargy
- Swellings
- Sleep
Cardiovascular
- Chest pain
- Palpitations
- Shortness of breath on exertion
- Waking up short of breath
- Number of pillows
- Ankle swelling
- Exercise tolerance
- Claudication
- Blackouts
Dermatology
- Rash = SOCRATES
- PMHx: systemic illness; allergy; atopy
- Previous dermatology history
- Social: occupation; exposures; travel
- Family history: infectious; sexual contacts
- S – site: of rash
- O -onset: how long; comes and goes
- C -characteristics: itchy; red; hot; weepy; blisters
- R – radiation: spread
- A – associations
- T– timing: had before
- E – exacerbating: sunlight; after exposure
- S – severity: same; worse; better
Ear, Nose and Throat
Ear
- Uni/bilateral
- Hearing loss (sudden; gradual)
- Vertigo
- Tinnitus
- Pain
- Swelling
- Discharge
- Trauma
- Foreign body
Nose
- Trauma
- Foreign body
- Discharge (uni/bilateral)
- Bleeding
Throat
- Dysphagia (acute; progressive)
- Odynophagia
- Voice changes
- Neck lump
- Cough
- Previous HPV infection; malignancy
Gastroenterology
ALARMS
- A – Anaemia
- L – Loss of weight
- A – Anorexia
- R – Recent/progressive
- M – Masses/melaena/haematemesis
- S – Swallowing
PLUS
- Heartburn
- Nausea/vomiting
- Bowel habit
- Pain
- Jaundice
- Pruritus
Genitourinary
- Frequency
- Urgency
- Pain on voiding
- Poor flow
- Incomplete emptying
- Incontinence
- Blood in urine
- Pelvic pain
- Changes in sexual function
Gynaecology
ABCD IFS
- Abdo pain (including dyspareunia)
- Bleeding: last menstrual period and usual pattern; intermenstrual, postcoital or postmenopausal bleeding
- Contraception and possibility of pregnancy
- Discharge: colour; smell; volume; consistency
- Itch; skin; incontinence
- Fertility: menarche; menopause; gravidity; parity
- Screening: cervical screening history and previous results
Musculoskeletal
- Pain
- Swelling
- Stiffness
- Deformity
- Function
Obstetric
Current pregnancy
- Gestation; EDD; single/twins
- Scan results; screening
- Folic acid
- Immunisations
Previous pregnancy
- Gravidity; parity; stillbirths
- Complications
- Birth weight
Specific questions
- Bleeding; discharge; fluid
- Abdominal pain
- Nausea or vomiting
- Foetal movements
- Headache, vision, oedema
- SOB; chest pain; leg swelling
- Pruritus
Ophthalmology
- Glasses or contact lens wearer
- Eye surgery
- Trauma
- Acuity change: rapid; gradual; intermittent
- Flashes; floaters; field loss
- Painful eye
- Red eye
- Tearing or discharge
- Headache
- Scalp temple tenderness or pain on chewing
- Weight loss; joint pains; fever
Respiratory
- Chest pain
- SOB
- Cough
- Wheeze
- Sputum
- Haemoptysis
Sexual
Ask permission, explain confidentiality and its limits, and use a private setting. Ask about relevant anatomy and sexual contact without assuming identity or practices.
Who and when
- Partners and the timing of recent contacts
- Consent, coercion and safety
- Partner symptoms, known infections and previous STIs
- Sex abroad or paid/exchanged sex, where relevant
What
- Types and sites of contact: oral, vaginal and/or anal
- Condom or barrier use
- Alcohol or drugs, including chemsex where relevant
Symptoms and prevention
- Genital or urinary symptoms, sores, discharge or pain; rectal symptoms where relevant
- Pregnancy possibility, last menstrual period and contraception where relevant
- Previous STI tests/treatment, HIV prevention and relevant vaccination
See also the genitourinary and gynaecology prompts.
Reference: BASHH sexual history-taking guidance.
Travel
Travel onset
- Symptom onset before, during or after travel
- Pattern of symptoms
Room and Board
- Urban vs rural
- Local food; unpasteurised dairy; drinking water
- Mosquito nets; screens
Activities
- Freshwater
- Saltwater
- Caves
- Barefoot
- Animal contacts
- Bush meat
Vaccination/pre travel preparation
- Vaccines?
- Malaria prophylaxis, doses taken and any missed doses
Exposure
- Medical care overseas; injections, procedures or transfusions
- Sick contacts and the dates of contact
- Tattoos
Location
- Exact itinerary
- Duration in each
- Stopovers
Paediatric
BFG EXTRA
Birth
- Gestation and weight
- Delivery mode and complications
- Neonatal problems
Feeding and elimination
- Milk feeds: breast/formula (type, amount and changes from usual)
- From around 6 months: introduction of solid foods alongside milk feeds
- From 12 months: varied foods and milk intake; breastfeeding may continue
- Number of wet/dirty nappies
Growth and Development
- Red Book (Personal Child Health Record); developmental milestones and any loss of previously acquired skills
Extras
- Medications
- Allergies
- Immunisations
Social history
- Family Unit
- Smoking
- Social Services
- Safety at home and safeguarding: hear the child’s account using age-appropriate, open questions; follow NICE guidance and local safeguarding procedures
- Education level
- Hobbies
Family
- Congenital problems
- Neonatal/infant deaths
- Sudden cardiac death <40 years old
05 / CHAPTER 3
References
Guidance for consultation, communication and the system-specific questions below.
- RCEM — domain-based OSCE marking
- NICE — patient-centred communication
- NHS England — standard infection control precautions
- GMC — intimate examinations and chaperones
- NICE PH50 — domestic violence and abuse
- NICE NG76 — child abuse and neglect
- BASHH — sexual history-taking guidance (2019, currently listed)
- RCPCH — Personal Child Health Record
- NHS — introducing solid foods and milk feeds
- UKHSA — travel history and returning travellers
- DVLA — assessing fitness to drive