History taking

Start with the person

Introduce yourself by name and actual role, check the patient’s identity and explain what you have been asked to do. Ask permission to continue, establish privacy and check whether hearing, language, cognition or another communication need requires support. Address pain or distress with the supervising team. Hand hygiene and personal protective equipment should fit the contact and infection risk; a spoken recital does not replace doing them when needed.

Begin with an open invitation such as “Could you tell me what has brought you here?” Let the patient describe the problem before narrowing the questions. Establish the sequence of events, the change from their usual health and the effect on everyday life. If there are several problems, agree which needs attention first and acknowledge the others.

Use the history to test possibilities

Move from the patient’s account to focused questions. For each important possibility, ask what would support it, what would make it less likely and what would change the urgency. Relevant negative findings belong in your presentation because they help explain your reasoning; a long list of unrelated negatives does not. Keep revising your view when new information emerges rather than forcing the story to fit your first diagnosis.

For example, “breathlessness” needs a time course, severity and baseline. Exertional limitation, orthopnoea, cough, fever, chest pain and relevant exposures help distinguish possible causes. Ask about the functional consequence in concrete terms: how far can the person walk now, and what could they do before? History directs examination and investigation; it rarely excludes a serious diagnosis on its own.

Place the problem in context

• Past health: relevant medical, surgical, mental health and obstetric or gynaecological history, previous episodes and treatment. A forensic history is appropriate only when clinically relevant, not a routine interrogation.
• Medicines: prescribed, over-the-counter, herbal and recreational substances; dose, use, recent changes, contraception where relevant and difficulties taking treatment. Ask what an “allergy” actually caused.
• Family history: the condition, relative and age affected matter more than a simple yes or no.
• Life and support: occupation, smoking, alcohol, substances, living arrangements, mobility, caring responsibilities, travel and access to help. Explore safety at home privately and sensitively.

Do not treat this as a compulsory opening questionnaire. Fit background questions around the clinical story, explaining transitions: “To understand what might be contributing, could I ask about your other health problems and medicines?” With an older person, distinguish a new loss of function or confusion from their usual state, using a collateral account with appropriate permission when necessary.

Finish with a shared understanding

Summarise the important findings and invite correction. Explain your working possibilities in plain language and what examination, investigations or review you propose. As a student, make clear that the responsible clinician will agree the clinical plan with the patient. If asked to demonstrate a discharge conversation in an assessment, include follow-up and specific safety-net advice: what change should prompt help, how urgently and through which route. Avoid claiming that a normal test rules out everything.

Check for unanswered concerns, thank the patient and hand over important findings promptly. Document the account accurately, distinguishing what the patient said, collateral information and your interpretation.

General symptoms

Weight change, appetite, fever, sweats, tiredness, lethargy, swellings and sleep can connect a local complaint to systemic illness. Establish duration and objective change where possible. “Weight loss” is more informative when you know the amount, timescale and whether it was intended.

Cardiovascular

Explore chest pain, palpitations, exertional breathlessness, orthopnoea, waking breathless at night, ankle swelling, exercise tolerance, claudication and blackouts. Clarify whether the patient adds pillows because of breathing difficulty or another reason. For a blackout, establish posture, activity, warning symptoms, witness account, duration and recovery; the patient’s word “faint” is a starting description, not a diagnosis.

Skin

Describe where the rash began, onset, spread and whether it itches, hurts, feels hot, weeps or blisters. Ask about associated illness, previous episodes, progression and effects of sunlight or other exposure. Review medicines, allergies, atopy and systemic disease, and ask about occupation, travel and affected close contacts. Use relevant sexual exposure questions sensitively. Distribution, time course and exposure are often more useful than asking the patient to name the rash.

Ear, nose and throat

For ear symptoms, establish one or both sides, sudden or gradual hearing change, vertigo, tinnitus, pain, swelling, discharge, trauma and possible foreign body. Sudden change needs timely clinical attention. For nasal symptoms, ask about obstruction, discharge, bleeding, trauma and foreign body, including whether symptoms are unilateral. For throat symptoms, distinguish difficulty swallowing from pain on swallowing; ask about progression, voice change, neck lump and cough. Relevant previous malignancy, treatment and exposures help interpret the account.

Gastrointestinal

Ask about abdominal pain, heartburn, nausea or vomiting, bowel habit, jaundice and itching. Characterise stool change and any bleeding rather than relying on “normal bowels”. The ALARMS reminder covers anaemia, loss of weight, anorexia, recent or progressive symptoms, masses or gastrointestinal bleeding, and swallowing difficulty. These are prompts to investigate concerning features, not a validated rule that excludes serious disease when absent. Clarify haematemesis, black stools, dysphagia and persistent vomiting promptly.

Urinary and genitourinary

Explore frequency, urgency, pain on passing urine, poor flow, incomplete emptying, incontinence, visible blood, pelvic pain and changes in sexual function. Establish onset, fluid intake, associated fever or pain and the effect on daily life. Ask about retention symptoms and relevant neurological symptoms when indicated. Describe incontinence in the patient’s own circumstances, such as leakage with coughing or an inability to reach the toilet, before assigning a type.

Gynaecology

Ask about abdominal or pelvic pain, including pain during sex; the last menstrual period and usual cycle; heavy, intermenstrual, postcoital or postmenopausal bleeding; contraception and the possibility of pregnancy. Characterise discharge by change, colour, smell, amount and associated itching or skin symptoms. Relevant urinary symptoms, fertility concerns, age at menarche or menopause, pregnancies and births, and cervical screening history complete the context. Do not infer anatomy, fertility or pregnancy possibility solely from a person’s identity or appearance.

Musculoskeletal

Explore pain, swelling, stiffness, deformity and loss of function. Establish whether stiffness is worse after rest or activity, which joints are involved and whether symptoms are symmetrical. Ask about injury, systemic symptoms and effects on work, mobility and self-care. “Can you manage the stairs?” often reveals more than “Any functional problems?” Compare the present state with the person’s baseline.

Pregnancy and maternity

Establish gestation, estimated due date, whether there is more than one fetus, antenatal care and relevant scan or screening results. Review medicines and supplements, immunisations and previous pregnancies, births, losses and complications sensitively. Ask about bleeding, vaginal fluid loss, abdominal pain, vomiting and fetal movements as appropriate to gestation. Headache, visual symptoms, swelling, breathlessness, chest pain, leg symptoms and itching may be important. Do not dismiss new symptoms as an inevitable part of pregnancy; communicate concerning findings promptly to the responsible maternity team.

Eyes

Ask about glasses or contact lenses, previous eye disease or surgery and trauma. Define visual change: one or both eyes, sudden or gradual, continuous or intermittent, and central or peripheral. Explore flashes, floaters, a curtain or field defect, pain, redness, watering or discharge. Relevant headache, scalp or temple tenderness, pain on chewing, weight loss, joint symptoms and fever may change the urgency. An acute visual complaint needs assessment rather than waiting to finish an unrelated systems review.

Respiratory

Explore breathlessness, chest pain, cough, wheeze, sputum and haemoptysis. Quantify the change in activity and distinguish breathlessness at rest from exertional symptoms. Ask about smoking, occupation, exposures, infection contacts, medicines and relevant cardiopulmonary history. For blood in sputum, establish the source, amount and course; do not assume all blood coughed up has come from the lungs.

Sexual health

Explain why the questions are relevant, establish privacy and describe confidentiality and its limits. Ask about partners and timing, types and sites of contact, barrier use, symptoms, previous infections or tests, contraception and pregnancy possibility where relevant. Include consent, coercion and personal safety. Ask about alcohol, drugs or chemsex and paid or exchanged sex when relevant to the assessment, using neutral language. Focus on actual contact and anatomy rather than assumptions about identity, nationality or relationship status. A recent exposure may require time-critical advice, so communicate its timing clearly.

Travel

Build a timeline linking symptoms to the exact itinerary, dates, duration and stopovers. Explore urban or rural accommodation, food and water, unpasteurised dairy, mosquito protection, freshwater or seawater exposure, caves, walking barefoot, animal contact and relevant foods. Check vaccines and malaria prophylaxis, including missed doses. Ask about sick contacts, medical or dental care, injections, transfusions and tattoos overseas. A destination alone is not an exposure history; establish what the person actually did and when. Flag illness after travel promptly when it could change infection-control or urgent investigation needs.

Children and young people

Hear the child’s account as well as the parent’s, using age-appropriate language. Establish birth gestation and weight, delivery and neonatal problems when relevant. Ask about actual feeding and change from usual, wet nappies or urine, stools, growth and development, including loss of previously acquired skills. The Personal Child Health Record can help establish growth and immunisation history. Review medicines and allergies, family structure and support, schooling, activities and safety. Relevant family history includes congenital disease, infant deaths and sudden cardiac death at a young age. Offer suitable privacy to adolescents and explain the limits of confidentiality; do not ask about possible abuse in front of a person who may be responsible.