Originally by Kate Chatten, Mary Howe, Gillian Marks and Tom Smith. Edited and
updated by Henry Tufton, Dr Alison Sturrock and Dr Deborah Gill. Further updates Dr
Jessica Bilaney, Dr Beth Walker, Dr Laura-Jane Smith and Mr David Gamble. Dr Helen
Nolan 2015 ©ACME 2015
The Medical History – Common Misconceptions
There is often confusion about what ‘a medical history’ is, because the term is used for
different things. It can mean:
the whole consultation in which information is gathered (i.e. including both the
process of communication, and the content, i.e. the information gathered)
only the clinical content (the medical information) which is gleaned during the
consultation
a written or presented version of the information gathered (e.g. in medical notes, a
student case presentation)
These are all very different – the key point being that how you conduct a consultation to
gather information to obtain ‘a medical history’ is not the same as how you subsequently
record it or communicate it to colleagues.
Common problems
1. Trying to gather the information in the order in which it is written or presented. The
information communicated to colleagues is a concise summary, presented in a
logical, linear manner. Consultations, whilst structured, allow the information to
unfold more slowly, often with parts being covered in a different order (e.g. the
patient may start their story with the onset of a problem some time ago, not their
current presenting symptom). Sometimes an additional line of questioning occurs to
you later, and you have to revisit a part of the history. In addition, there may be
much clarification of terminology used – such as the patient’s description of their
symptoms – which in the notes might be summarised simply as ‘complains of
pressing pain in chest’.
You will have training in how to structure the consultation, but be aware that you are
not expected to cover everything in the same order in the consultation as in a
subsequent case presentation.
Example: At the start of a case presentation, you might begin with the patient’s age,
gender, occupation and marital status. However, asking the patient’s occupation and
marital status as your second and third questions can appear intrusive and/or
irrelevant - the patient is expecting to tell you about their medical problem first. It is
more appropriate to ask about these later on in the consultation, when you are
opening up the discussion to talk more generally about their lifestyle.
2. Clinical students become rapidly socialised into the use of medical jargon, which is
then unintentionally used with patients. Case presentations and medical notes are
full of jargon; it is concise. Consultations should not be.
Example: The word ‘history’. You would not, in a consultation, start a line of
questioning by saying ‘Now, what about your social history?’. You would say ‘I’d
just like to ask you about your life in general, to get a better picture of your health.
First of all, who’s at home with you?…’
Other common jargon to avoid: ‘drugs’ (meaning prescribed or over the counter
medication), and reading straight from a list whilst doing your systems review (e.g.
‘anything associated with this?’, ‘does it radiate?’).