11/13/24, 8\:11 PM Guide | Presenting a history

Presenting a history

Table of contents

Introduction

Taking a detailed history is important, but it is equally important to be able to communicate the information you gather
e
Presenting a history in a structured and clear way is a valuable skill for OSCEs and clinical practice.
Depending on the situation, presentations can last anywhere from a few minutes (much like an SBAR) to more than 10 minutes
for complex patients with new presentations. However, the approach to these presentations is similar - they aim to convey full,
pertinent information to a listener unfamiliar with the patient.
This guide provides a step-by-step approach to presenting a history, including an example patient presentation.

Tips for presenting a history

Con

Con
that you are sure of the information you have gathered.
Speak clearly and loudly enough to be understood by colleagues.

Using notes

If you took notes during your consultation, feel free to refer to them, but try not to read them straight o
notes don’t always translate to an e
It can be tempting to say all the information you have gathered when reading from notes, but remember that you should have a
reason for each sentence within the presentation.

Time management

Be aware of how much time you have to ensure you communicate all the relevant information.
This is especially important in an OSCE setting, where the time may be limited (e.g. 1 - 2 minutes). In this situation, it is important
to prioritise the most relevant information which has led you to your di

Be honest

Never guess or report false positives/negatives in the patient presentation.
If you are unsure, say so and why, rather than implying something without being certain or giving the implication of normality,
especially if you omitted part of an examination.

Structuring the presentation

This should be a brief one-line summary containing the patient’s name, age, presenting complaint and key past medical

Opening

history.
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The presenting complaint is often why the patient sought medical attention initially and should form the basis for further
details you report in the presentation\:
"M r s S m i t h i s a 6 6- y e a r-o l d w o m a n p r e s e n t i n g w i t h r i g h t-s i d e d h i p p a i n o n a b a c k gr o u n d
o f o s t e o a r t h r i t i s"
.
If the patient is presenting as a follow-up visit to outpatients and does not have a presenting complaint, you can include other
relevant details (e.g. reason for attendance or referral)\:
"M r s S m i t h i s a 5 8- y e a r-o l d w o m a n p r e s e n t i n g t o c l i n i c f o r f o l l o w-u p o f
o n g o i n g l o o s e s t o o l a n d b l o a t i n g w i t h o u t o b v i o u s c a u s e .
"

History of presenting complaint

For any patients presenting with pain, brieSOCRATES. For example\:
S\: Right hip pain
O\: Started 18 months ago, has been getting worse
C\: Dull ache
R\: Radiates to groin and lateral aspect of the thigh
A\: Can get knee pain occasionally but not recently
T\: Occurs when standing for long periods
E\: Painkillers not helping, sitting sometimes helps, strenuous activity makes it worse
S\: Pain is 4/10 in clinic today, can get to 9/10 at worst
" T h e d u l l a c h e i n h e r r i g h t h i p h a s w o r s e n e d o v e r t h e p a s t 1 8 m o n t h s , r a d i a t i n g t o h e r g r o i n a n d l a t e r a l t h i gh . T h e r e a r e n o
s i g n i
"
For any patient presenting with system-speci
" D i a r r h o e a s t a r t e d 3 w e e k s a g o
w i t h n o o b v i o u s t r i g g e r . N o p a i n , b l o o d o r m u c o u s . P a s s i n g s t o o l 3 t i m e s p e r d a y a t 6 o n B r i s t o l s t o o l c h a r t . B l o a t i n g o c c u r s 1
h o u r a f t e r m e a l s a n d i s u n c o m f o r t a b l e b u t n o t p a i n f u l . N o r e c e n t c h a n ge s t o d i e t .
"

Other important positive and negative

At this stage, it is important to highlight any positive or negative
sinister cause, or an emergency.
Avoid listing all negative
speci
Commenting on how the patient feels generally is appropriate here. Although systemic enquiry normally occurs at the end
when taking a history, any relevant symptoms can be presented here\:
" M r s S m i t h d i d n o t d e s c r i b e a n y u n i n t e n t i o n a l w e i g h t
l o s s , f e v e r s , n i g h t s w e a t s , o r r e c e n t t r a u m a . S h e i s o t h e r w i s e s y s t e m i c a l l y w e l l .
"

Past medical history

To aid memory, the past medical history can be divided into\:
Conditions relevant to the presenting complaint
Chronic conditions and how well they are being managed
Surgical history
Past hospitalisations
Not all procedures will be relevant to the presenting complaint (in this example, Mrs Smith’s appendicectomy in 1986), but it is
important to report any complications, especially if the patient is being considered for a surgical pathway\:
" S h e w a s d i a g n o s e d
w i t h l e f t h i p o s t e o a r t h r i t i s i n 2 0 1 6 , l a r ge l y a s y m p t o m a t i c s i n c e a l e f t h i p r e p l a c e m e n t i n 2 0 1 8 ; a d i a g n o s i s o f t y p e 2 d i a b e t e s i n
2 0 1 9 , m a n a g e d b y d i e t ; n o t h i n g e l s e o f s i gn i
"

Drug history

Listing all current medications may not be appropriate, especially for more complex patients. If this list is long, highlight
important medications (e.g. takes X for Y condition). Important medications that patients are not taking should also be
included.
For example, if a patient is being considered for surgery, it is important to know if they are on anticoagulants, as these will
need to be stopped before surgery. Or, if a patient is presenting with infective symptoms, their condition may be exacerbated if
they are on long-term steroids (e.g. rheumatological conditions) or immunosuppressants (e.g. transplant patients).
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Additionally, medications with a high prevalence of interactions, such as anti-psychotics, would be relevant if symptoms may
be due to a medication interaction or the patient may require a new medication to be prescribed.
Always remember to mention allergies and symptoms experienced when they encounter allergens.
For example,
o n s t e r o i d s , " S h e t a k e s n a p r o x e n 5 0 0 m g o n c e d a i l y , o m e p r a z o l e 2 0 m g o n c e d a i l y , b l o o d t h i n n e r s o r b i s p h o s p h a t e s . N o k n o w n a l l e r g i e s .
"
a n d a n o v e r-t h e-c o u n t e r m u l t i v i t a m i n . N o t

Family history

Patients may have an extensive family history of various conditions. It is important to report any conditions relevant to the
presenting complaint. For example, in a hip fracture, a family history of Perthe’s disease would be relevant, but a family history
of diabetes in a patient with known diabetes would be less relevant\:
" F a m i l y h i s t o r y s i g n i
d i s e a s e a n d h e r f a t h e r h a d b i l a t e r a l h i p r e p l a c e m e n t b y a ge 6 5 . N o t h i n g e l s e o f n o t e .
"
Family history may be more important in certain situations. For example, if a genetic condition is suspected in a paediatric
patient.

An overview of how the patient normally performs activities of daily living (AoDL) is helpful, rather than a complete report on
their daily activities. This allows care plans to aim for the patient to resume normal or improved function after discharge. It is
important to mention if the patient is dependent or independent at home, especially following an inpatient stay.
Other relevant details include occupation, alcohol intake, smoking history and specialty-speci
history in patients with infective symptoms or religion if providing medications with animal products or blood transfusions).
For example,
" B e f o r e t h i s e p i s o d e o f p a i n , s h e m o b i l i s e d i n d e p e n d e n t l y b u t i s c u r r e n t l y
h o m e . S h e l i v e s w i t h h e r h u s b a n d a n d w o r k s a s a s c h o o l s e c r e t a r y ; h e r w o r k i s u n a
a n d o n l y d r i n k s a l c o h o l s o c i a l l y .
"

Examination

If incorporating examination
recounting the whole examination.
Providing the NEWS score and stating which observations are abnormal is good practice. This is especially important for sick
patients.
Provide an overview of the stages of the examination\:
General inspection\: do they appear well? Any notable
Close inspection\: any positive features of disease?
Avoid reporting
, instead report the
and passive movement)
Report relevant positive and negative
auscultation, anterior drawer test positive)
For example,
" M r s S m i t h a p p e a r s i n p a i n a t r e s t , N E W S s c o r e 0 . N o o b v i o u s a b n o r m a l i t i e s o n c l o s e i n s p e c t i o n , p a i n o n a c t i v e
m o v e m e n t a n d g l o b a l l y r e d u c e d r a n ge o f m o v e m e n t i n t h e r i gh t h i p . N o p a i n o r r e s t r i c t i o n i n t h e l e f t h i p . N o c o n c e r n i n g
f e a t u r e s o n e x a m i n a t i o n o f k n e e s a n d s p i n e . S t r a i gh t l e g r a i s e s n e ga t i v e b i l a t e r a l l y .
"

Investigations

If the patient has any recent, relevant investigation
overall picture of the patient and prevent the repetition of unnecessary investigations. Also, if the patient has had these
investigations completed previously, it is helpful to state how long the time between results is and any changes that have
occurred.
For inpatient presentations, it may be appropriate to mention investigations which have been requested but not yet
undertaken (e.g. imaging).
For example,
" R o u t i n e b l o o d s s h o w a m i c r o c y t i c a n a e m i a . T h e m o s t r e c e n t X -r a y s h o w s l e f t h i p r e p l a c e m e n t a n d n a r r o w i n g o f
j o i n t s p a c e i n t h e r i g h t h i p , w h i c h h a s n o t p r o gr e s s e d s i gn i
.
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Summary

Recap the opening line of the presentation to close. If required, state your overall impression of the patient and any di
diagnoses you have at this stage, with relevant supporting information.
State your plan. Are there any further examinations, investigations, or information you want to gather? This can include
contacting other departments for input and contacting relatives/care homes for a collateral history.
If you have any questions for your senior at this stage, you can ask what their recommendations are or if there is anything they
wish to clarify.
" I n s u m m a r y , t h i s i s a 5 8- y e a r-o l d l a d y p r e s e n t i n g w i t h a n 1 8-m o n t h h i s t o r y o f w o r s e n i n g r i gh t-s i d e d h i p p a i n o n a b a c k gr o u n d
o f o s t e o a r t h r i t i s a n d t y p e 2 d i a b e t e s , w i t h n o r e d
r e l a t e d t o p r o g r e s s i n g o s t e o a r t h r i t i s , n o c u r r e n t c o n c e r n s a b o u t h i p f r a c t u r e o r i n f e c t i o n , a l t h o u g h i m p o r t a n t t o r u l e o u t m u s c l e
s t r a i n a n d s c i a t i c a .
"

Example patient presentation

The following example patient presentation takes approximately 2 minutes but covers all the salient points and provides an
overview of the patient.
" M r s S m i t h i s a 6 6- y e a r-o l d l a d y p r e s e n t i n g w i t h r i gh t-s i d e d h i p p a i n o n a b a c k g r o u n d o f o s t e o a r t h r i t i s .
T h e d u l l a c h e i n h e r r i g h t h i p h a s w o r s e n e d o v e r t h e p a s t 1 8 m o n t h s , r a d i a t i n g t o h e r g r o i n a n d l a t e r a l t h i gh . T h e r e a r e n o
s i g n i
M r s S m i t h d i d n o t d e s c r i b e a n y u n i n t e n t i o n a l w e i gh t l o s s , w e l l .
f e v e r s , n i g h t s w e a t s , o r r e c e n t t r a u m a . S h e i s o t h e r w i s e s y s t e m i c a l l y
S h e w a s d i a g n o s e d w i t h l e f t h i p o s t e o a r t h r i t i s i n 2 0 1 6 , l a r g e l y a s y m p t o m a t i c s i n c e a l e f t h i p r e p l a c e m e n t i n 2 0 1 8 ; d i a gn o s i s o f
t y p e 2 d i a b e t e s i n 2 0 1 9 , m a n a g e d b y d i e t ; n o t h i n g e l s e o f s i g n i
S h e t a k e s n a p r o x e n 5 0 0 m g o n c e d a i l y , o m e p r a z o l e 2 0 m g o n c e d a i l y , b l o o d t h i n n e r s o r b i s p h o s p h a t e s . N o k n o w n a l l e r gi e s .
a n d a n o v e r-t h e-c o u n t e r m u l t i v i t a m i n . N o t o n s t e r o i d s ,
F a m i l y h i s t o r y s i g n i
N o t h i n g
B e f o r e t h i s e p i s o d e o f p a i n , s h e m o b i l i s e d i n d e p e n d e n t l y b u t i s c u r r e n t l y
w i t h h e r h u s b a n d a n d w o r k s a s a s c h o o l s e c r e t a r y ; h e r w o r k i s u n a
a l c o h o l s o c i a l l y .
M r s S m i t h a p p e a r s i n p a i n a t r e s t , N E W S s c o r e 0 . N o o b v i o u s a b n o r m a l i t i e s o n c l o s e i n s p e c t i o n , p a i n o n a c t i v e m o v e m e n t a n d
g l o b a l l y r e d u c e d r a n g e o f m o v e m e n t i n t h e r i gh t h i p . N o p a i n o r r e s t r i c t i o n i n t h e l e f t h i p . N o c o n c e r n i n g f e a t u r e s o n
e x a m i n a t i o n o f k n e e s a n d s p i n e . S t r a i g h t l e g r a i s e n e ga t i v e b i l a t e r a l l y .
R o u t i n e b l o o d s r e v e a l a m i c r o c y t i c a n a e m i a . T h e m o s t r e c e n t x-r a y s h o w s l e f t h i p r e p l a c e m e n t a n d n a r r o w i n g o f j o i n t s p a c e i n
t h e r i g h t h i p , w h i c h h a s n o t p r o g r e s s e d s i gn i
I n s u m m a r y , t h i s i s a 5 8- y e a r-o l d l a d y p r e s e n t i n g w i t h a n 1 8-m o n t h h i s t o r y o f w o r s e n i n g r i gh t-s i d e d h i p p a i n o n a b a c k gr o u n d o f
o s t e o a r t h r i t i s a n d t y p e 2 d i a b e t e s , w i t h n o r e d
p r o g r e s s i n g o s t e o a r t h r i t i s , n o c u r r e n t c o n c e r n s a b o u t h i p f r a c t u r e o r i n f e c t i o n , a l t h o u gh i m p o r t a n t t o r u l e o u t m u s c l e s t r a i n a n d
s c i a t i c a .
"

Important points by specialty

Some points in a patient presentation may be more relevant depending on their presenting complaint and the medical
specialty involved in their care or the referral.
These can be based on common conditions which are easily excluded, red
features which in
description.
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This is not an exhaustive list but is designed to illustrate the di
context.
Table 1. Key patient presentation points by specialty.
Specialty Points to cover Reasoning
Any
Cardiology
Respiratory
Gastrointestinal
Paediatrics
Dermatology
Orthopaedics
Fever, night sweats,
weight loss, blood in
sputum/vomit
/urine/stool
Hypertension, diabetes,
hyperlipidaemia, chronic
kidney disease
Breathlessness, ankle
swelling
Smoking, travel history,
allergies, atopy, pets,
occupation
Changes in bowel habit,
travel history, recent
medication changes (e.g.
aspirin, opioids), red
(dysphagia/weight loss),
alcohol use
Coryzal symptoms, work
of breathing, milestones,
social services
involvement, behaviour
changes,
prenatal/birth/neonatal
complications
Travel history, signi
sun exposure,
pacemaker, atopy,
immunosuppression,
occupation
Hand dominance,
weight-bearing,
occupation, gait,
anaesthetic history, blood
thinners
Common symptoms of
malignancy and/or
sepsis
Risk factors for
cardiovascular disease
Suggestive of heart
failure
All can cause di
respiratory diseases
with similar
presentations
Eliminating any
infectious causes and
approximating the
location of the problem
within the GI tract is
always useful
Describing an overview
of any potential
safeguarding issues at
the outset of the
presentation.
Eliminating any
common or congenital
cause for presentation.
Assessing patient’s risk
factors for developing
skin lesions.
Also, to assess
suitability for
procedures to remove
any lesions.
How impactful is the
injury on their day-to-
day life? Any history of
surgical complications
or current medications
at risk of causing
signi
operative bleeding.
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Ophthalmology
Autoimmune conditions,
atopy, diabetes,
hypertension, driving, use
of glasses/contact
lenses
Establishing if there are
any underlying
conditions which need
treatment to resolve
the eye symptoms.
Safety regarding day-
to-day activities.
Neurology
Visual disturbance,
reduced /loss of
consciousness, trauma,
driving, occupation
Assessing if the patient
is acutely unwell or
safe to discharge.

Reviewers

1. Consultant in Intensive Care Medicine
2. Dr Jess Speller | Junior doctor

References

Source\: geekymedics.com
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