General History Structure

Question 1

How should you start all your history stations?

Answer 1

Start with WINDEC

Wash hands
Introduction (Full name)
Name
DOB
Explanation (I have been asked to take a medical history from you today)
Consent (Is that okay?)

Question 2

After WINDEC, what happens next?

Answer 2

Presenting complaint – open ended question – 2 open ended questions to start
i. What has brought you in today?
ii. Can you tell me a bit more about that?

History of presenting complaint – allow patient to speak and then refer back to the symptoms/complaints.
i. Delve deeper into the symptoms experienced - SOCRATES - Site, Onset, Character, Radiation, Associated features, Timing, Exacerbating/relieving factors and severity
- NOTEP - Nature, onset, timing, exacerbating/relieving factors and progression
ii. Run through check list of main symptoms associated with that system and any systemic symptoms

Consider summarising at this point

Question 3

After PC and HPC, what could you consider doing?

Answer 3

ICE
Ideas - What do you think might be going on?
Concerns - What are your concerns? How is this illness/symptoms influencing your day-to-day life?
Expectations - What are you expectations did you have coming to your appointment today?

Question 4

What four sections do you want to cover in the second half of the history?

Answer 4

Past medical history: significant past diseases/illnesses; surgery

Medication history: prescribed and over-the-counter medicines, allergies.

Family history: especially parents, siblings

Social history: smoking, alcohol, recreational drugs, accommodation and living arrangements, baseline functioning, diet (GI!), exercise, occupation, pets and hobbies.

Question 5

How can you conclude a history station?

Answer 5

Concluding the History

• Summarise the main points.
• Ask the patient at the end of the consultation if they have anything else they wanted to discuss.
• Thank the patient.