Preparatory Mindset
History taking (问诊) is the first step of doctor-patient communication and the main method of gathering clinical information. A well-taken history contributes to roughly 50% of diagnoses. The goal is not just to list symptoms but to understand two frameworks simultaneously: the disease framework (what is the diagnosis?) and the illness framework (what are the patient's experience, ideas, expectations, and feelings?). Use open-ended questions first, then clarify — and always practice active listening, empathy, and patience.
Core Concepts
Doctor–Patient Communication Skills
- Communication = the process of establishing consensus, sharing benefits, and developing relationships through multi-channel information exchange.
- Basic ability structure: professional attitude, nonverbal expression, active listening, oral expression, negotiation and conflict resolution.
- 73855 rule: Words 7% / Tone 38% / External image & body 55% — how you say it matters more than what you say.
- Difficult patients: silence/sorrow, chatter/hostile, anxious/angry, elderly, children, mental disorder, language difficulty → stay calm, listen, use eye contact, empathy, never rush, avoid taking too many notes.
- Telling bad news requires teamwork (anesthetist, nurses, pharmacist, nutritionist, relatives, etc.).
Basic Structure of the Medical History Record
- General data — name, age, sex, marriage, address, nation, occupation, working place, recording date, informant, reliability
- Chief complaints (主诉) — the main reason for seeking care: symptom/sign + time, 1–2 sentences (e.g. "Paroxysmal chest pain for 2 months")
- Present illness history (现病史) — the main body of the record. Include: onset and time; speed of onset; characteristics of main symptoms; etiological/inducing factors; development and progress; associated symptoms; procedure of previous diagnosis and treatment; general condition
- Past history (既往史) — previous hospital admissions, operations, known medical/psychiatric conditions, risk factors, immunizations, allergies, trauma
- Review of systems (系统回顾) — GI, genitourinary, respiratory, cardiovascular, hematologic, skeletal, nervous, psychological, endocrine, sense organs
- Personal/social history (个人史) — work, hobbies/habits (smoking, drinking, drugs), environment, travel, stress
- Marital history (婚姻史) — age at marriage, spouse's health
- Menstrual & childbearing history (月经及生育史) — menarche, cycle, LMP, menopause, parity
- Family history (家族史) — heredity, infections, common environment
Pain History — OLD CART / SOCRATES
| OLD CART | SOCRATES |
|---|---|
| Onset | Site |
| Location | Onset |
| Duration | Characteristics |
| Characteristics | Radiation |
| Aggravating factors | Accompanying symptoms |
| Relieving factors | Time course |
| Treatment | Exacerbating/relieving factors |
| Severity |
- Chest pain (cardiac): "tight", "crushing", "like a band across my chest", radiation to throat/left arm
- Pleuritic pain: sharp, stabbing, aggravated by coughing/deep breathing
- Abdominal pain: related to food ingestion, vague, burning, acid taste in the mouth
General Inspection during Physical Examination
- Vital signs: temperature, pulse, respiration, BP
- Development: ortho-sthenic (正常), asthenic (不良), sthenic (超常)
- Nutrition: well, fairly, poor, cachexia
- Facial features: acute (急性), chronic (慢性), normal
- Position: active, semi-recumbent, etc. Gait: normal/abnormal
- Consciousness: aware, somnolence, confusion, stupor, coma, delirium
- Mucocutaneous: color (pale, cyanosis, jaundice), rash, subcutaneous hemorrhage, edema, spider angioma, liver palm
- Lymph nodes: non-swelling / swelling (site and characteristics)
High-Yield Points
- History taking is the first step of doctor-patient communication and the main method of information gathering
- Chief complaint format: symptom + duration (never write a diagnosis)
- Present illness = the detailed whole process of the current illness
- Open-ended questions first ("Did your pain come suddenly or gradually?") — avoid leading/closed questions ("Did your pain come suddenly?")
- Ask about pain: site, radiation, nature, severity, time course, aggravating factors, relieving factors, associated symptoms
- Never take too many notes; make eye contact; patient-centered
- Review of systems includes: GI, cardio-respiratory, neuro, urinary, menstrual, skin, joints, etc.
LMCHK OSCE Practice
- Start any history/exam with: greeting + self-introduction + consent + curtain + chaperone (for opposite sex) + hand hygiene
- Script: 「你好，我是XX醫生。今天要幫你做一個XX檢查。請問你同意嗎？」→ state consent/curtain/chaperone/hygiene → "I will adjust the bed and ensure adequate exposure. 先生，有沒有哪裡痛？請告訴我如果有不舒服。」
- History-taking is tested in long cases (LMCHK: 40 min history + exam, then 20 min questioning; Paeds: 20 min clerk with surrogate + 10 min discussion)
- Always ask about: symptoms onset, characteristics, aggravating/relieving factors, associated symptoms, prior treatment, past medical history, social history, family history
- Communicate the "illness framework" — patient's ideas, concerns, expectations — in addition to the disease
Topic Summary
History taking is the foundation of diagnostics — it drives ~50% of diagnoses. Follow the 9-part structure (general data → chief complaint → present illness → past history → systems review → personal → marital → menstrual → family). Use open-ended questions, active listening, and a patient-centered approach. For exams and OSCEs, always open with the communication script (consent, curtain, chaperone, hygiene) and systematically explore pain with OLD CART/SOCRATES.