Obtaining a full history is done in conjunction with examining the patient
In a sick patient this entails a full assessment of all systems
In a patient who has a localised problem it is reasonable to examine the relevant system
only. However, always be guided by the history and be prepared to examine other systems as
necessary. This is particularly important for children who often present with generalised symptoms
and signs. See ASSESSMENT OF THE SICK CHILD
However, all patients should have basic observations taken. These include:
pulse rate, blood pressure, respiratory rate, temperature and (often) oxygen saturation
In all patients the first priority is to assess whether the person is seriously ill and needs immediate management, or is less acutely sick – giving time for obtaining a full history. When obtaining a history, always ask “open” questions.
Presenting Concerns
Ask the patient what the problem is
Ask about length of illness and exact details of symptoms and signs. For each symptom the
following details are important:
Onset and duration (when did it start? gradual or sudden onset?)
Intensity (mild, moderate or severe?)
Site and radiation (eg. where is the pain? does the pain go elsewhere?)
Character (eg. sharp pain, dull pain, burning pain)
Associated features (eg. nausea, vomiting)
What makes it better or worse (eg. lying down, going for a walk)
Patients often don’t mention particular symptoms, thinking that they are not relevant.
Therefore, always specifically ask about:
Fever, pain, shortness of breath, diarrhoea, weight loss
Past Medical History
Any significant illnesses in the past?
Any hospital admissions?
Any operations?
Patients often don’t mention particular illnesses, thinking that they are not relevant.
Therefore, always specifically ask about:
Diabetes, hypertension, angina and heart attacks, epilepsy, asthma
Family and Social History
Health problems in the family – especially siblings and parents
Job, marital status, housing, who else lives at home
Smoking – how many? ever tried giving up?
Alcohol – how much and how often? Remember that most will under-estimate. Express in standard
drinks per day or week. Particularly in women who are in early pregnancy or likely to become
pregnant
Ask about the use of other ‘recreational’ drugs
Medications
Is the person on regular medications? (prescribed, herbal, bush medicine?)
Are they taken correctly?
Ask for the names of any medication being used; if necessary ask to see the container
Specifically ask females whether they are on the oral contraceptive pill
Allergies
Try to be specific. Find out the type of reaction suffered with medications (it still may be
appropriate to use in some circumstances), foods etc.
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