Shoulder Anatomy | Basic Facts
May 5, 2026
Shoulder Anatomy | Basic Facts The shoulder is a marvel of human evolution, providing the greatest range of motion of any joint in the body. This flexibility allows us to reach, throw, lift, and...
“80% of a diagnosis comes from the history alone.”
In modern medicine, tests and scans are vital, but history taking remains a doctor’s most important skill. This is true for all types of doctor.
Whilst physical examination and investigations contribute roughly 10% each to a diagnosis, a well-taken history provides the remaining 80%. For some illnesses, it is 100%.
Mastering this art takes time—often a decade of post-qualification experience—but you can fast-track your progress by mastering a structured, patient-centered approach.
To ensure no stone is left unturned, every clinical consultation should follow this universal framework:
Introduction & Consent
Presenting Complaint (PC)
History of Presenting Complaint (HPC)
Past Medical & Surgical History (PMH/PSH)
Drug & Allergy History (DH)
Social History (SH)
Family History (FH)
Ideas, Concerns, and Expectations (ICE)
Systems Review (SR)
Note. A junior student will need 30 mins for a history; a senior student or junior doctor will need 15 mins; a senior needs 5 minutes. It take decades to get it down to that. Sorry.
1. The Introduction: Setting the Tone
The first 60 seconds (called the ‘golden minute’) determines whether a patient will trust you. If they do not trust you, you will not get all relevant information out of them.
The Question: “Hello, my name is [Name], and I’m a [Year] medical student or doctor. You are Mr Smith/Mrs Singh and you are 57 years old .. is that correct” (Wait for them to confirm)
Pro Tip: Always confirm age directly. Asking for a Date of Birth requires mental maths that distracts you from the patient – and takes time.
The Handshake: A handshake is both a greeting and part of the clinical assessment. Note the temperature, grip strength, and nail condition (e.g. clubbing or cyanosis).
2. Presenting Complaint (PC)
The Question: “Thankyou for coming to see me. What is the problem today, and when did it start?”
Why it matters: This is the patient’s ‘headline.’ Listen without interrupting for at least 30 seconds. The diagnosis is often in their answer.
3. History of Presenting Complaint (HPC)
This is the ‘meat’ of the history. Use the SOCRATES acronym for pain, but for general symptoms, focus on onset, duration, and triggers.
The Questions: “Can you tell me more about the pain/problem? For example, did it come on suddenly or gradually? What makes it better or worse?” Listen without interupting for another 30 seconds (60 if necesary).
Pro Tip: If you’re struggling to pin down a timeline, ask: “When were you last 100% well?” This provides a clear anchor point for the onset of illness.
Note 1. The speed of onset of an illness (especially a pain) is vital to the differential diagnosis. Pains can come on suddenly, rapidly and slowly.
Note 2. Doctors are good at talking. Good doctors are very good at listening. Be quiet and listen carefully, especially in this first minute (or 1 min 30 sec) of introduction and PC.
4. Past Medical & Surgical History (PMH/PSH)
Don’t just ask “Are you healthy?” Patients often forget chronic stable conditions they’ve ‘lived with’ for years.
The Question: “Have you ever had major operations?” “Do you have ever had diabetes, jaundice, anaemia, TB, heart attacks or strokes, high BP, epilepsy, rheumatic fever or ulcers in the tummy?” “Any other major illnesses in your life?”
Note: Use the word “Major” for surgery to avoid a long list of minor procedures that may not be relevant to the current acute issue.
5. Drug & Allergy History (DH)
A Question: “What medications do you take regularly? is not helpful. It usually leads to an answer “I don’t know, I’ve forgotten or a little red one”
Better question: “Do you have an up-to-date list of your tablets I can see?”
Note: Up to 20% of hospital admissions are directly related to medication errors and side effects. You may need to ask about over-the-counter supplements and herbal remedies as well.
6. Social History (SH): The Patient’s Context
The Questions: “Are you married?” “Who do you live with?” “How many children do you have?”
Reframing: Instead of “Do you drink?” or “Do you smoke?”, ask “Have you ever smoked?” and “Have you ever been a regular and heavy drinker?” These are less accusatory and often yield more honest answers.
7. Family History (FH)
The Focus: You are looking for genetic predispositions.
The Questions: Depending on the patient’s age ask, “Are you parents well?” or “Are you parents still with us?” or “What did your parents die of?”
8. ICE: Ideas, Concerns, and Expectations
This is the most skipped step, yet the most important for patient satisfaction.
Ideas: “What do you think might be causing this?”
Concerns: “Is there anything in particular you are worried this might be?”
Expectations: “What were you hoping we could do for you today?”
9. Systems Review
As you get more senior, you will need this less as you will ‘pick and choose’ questions from it and insert them into the HPC. Anyway, here are some useful questions you may use.
Cardiovascular/Respiratory: “Have you had any chest pain, shortness of breath, or ankle swelling?”
Gastrointestinal: “Have you noticed any persistent change in your bowel habit, or any blood in your stool?”
Genitourinary: “Are you having any pain when passing urine, or have you noticed any blood in your urine?”
Neurological: “Have you experienced any sudden blackouts, dizziness, visual problems or persistent headaches recently?”
Systemic/Constitutional: “Have you had any unintended weight loss, night sweats, or unexplained fevers?”
Taking the history is only half the job. You must be able to communicate it to senior clinicians. Use this template:
If you have examined the patient ..
5. Examination: On examination there was nothing to find.
Wait for examiners question ..
Impression: “The most likely diagnosis is an Acute Coronary Syndrome (ACS).”
Note. Avoid relevant or irrelevant negatives, e.g. “he does not have diabetes and lives with his wife”
Avoid Jargon: Don’t ask about “dyspnoea”; ask about “shortness of breath.”
The “Poor Historian” Myth: The poor historian is you. If the history is bad, it’s usually the doctor’s fault. You are the historian; the patient is the witness.
Humanise the Patient: Avoid labeling. A patient is not “a diabetic, epileptic or alcoholic”; they are “a person with diabetes.” Doctors don’t do adverbs, or judge people.
Recommended Video Resource
For a visual demonstration of these techniques, watch this clinical skills guide: How to Take a Medical History – Prof. Vinod Patel
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