History taking & The Med Den Method

Basic Calgary-Cambridge Model by Kurtz and Silverman in 1996 ; link to image

The Med Den system does not replace Calgary-Cambridge. Instead, it helps answer the most important question during the information gathering phase:

"What is going on with this patient?"

Many students learn these stages well but struggle with what to think about whilst gathering information.

This is where The Med Den system helps.

The Med Den System

Whenever a patient presents with a symptom, ask yourself four questions:

1. What is the patient actually saying?

Before jumping to diagnoses, define the symptom.

Patients often use words differently from clinicians.

For example:

• "Dizziness" may mean vertigo, light-headedness, imbalance, or pre-syncope.

• "Chest pain" could be pain, pressure, tightness, burning, or discomfort.

• "Weakness" may represent fatigue, breathlessness, pain, or true loss of power.

A diagnosis cannot be made until the presenting complaint is clearly defined.

2. What is the worst thing this could be?

Every symptom has diagnoses that cannot be missed.

Examples include:

• Chest pain → Acute coronary syndrome

• Headache → Subarachnoid haemorrhage

• Back pain → Cauda equina syndrome

• Shortness of breath → Pulmonary embolism

These diagnoses guide your red flag questions.

3. What is common?

Medicine is often about balancing risk with probability.

While dangerous diagnoses must be considered, common conditions remain common.

For chest pain this might include:

• Musculoskeletal chest pain

• Gastro-oesophageal reflux disease

• Anxiety-related symptoms

For headache this might include:

• Tension headache

• Migraine

Your history should help distinguish common conditions from serious alternatives.

4. What investigation or finding would change my differential diagnosis list?

As information is gathered, ask:

"What piece of information would move a diagnosis up or down my list?"

Examples:

For chest pain:

• ECG changes

• Raised troponin

• Pain reproducible on palpation

For shortness of breath:

• Oxygen saturations

• Peak flow

• Chest X-ray findings

For abdominal pain:

• Urine dip

• Pregnancy test

• Blood tests

This question helps focus your history, examination, and investigations.

How The Med Den System Fits Into The Consultation

The Med Den system sits primarily within the gathering information and physical examination stages of the consultation.

It helps you:

• Define the symptom

• Generate differential diagnoses

• Identify red flags

• Ask focused questions

• Select appropriate examinations

• Choose useful investigations

Once enough information has been gathered, you move into the next stage of the consultation.

A Note on SOCRATES & introducing ‘OTAPS’

SOCRATES is an excellent tool for assessing pain. However, one of the most common mistakes medical students make is trying to force it onto every presentation.

Many symptoms are not pain-related. For example:

• Fatigue

• Weight loss

• Dizziness

• Low mood

• Breathlessness

• Falls

For these presentations, SOCRATES can feel unnatural and often misses important information.

Over time, I have found the following framework useful for almost any symptom presentation:

OTAPS

O: Onset

When did the symptom begin?

Consider:

• Sudden or gradual onset?

• Has it remained stable, improved, or worsened?

• Was there a triggering event?

T: Timing

When does the symptom occur?

Consider:

• Constant or intermittent?

• Worse at a particular time of day?

• Any cyclical or recurring pattern?

A: Associated Symptoms

What else is happening?

This is where your differential diagnoses begin to guide your questioning.

For example:

• Chest pain → breathlessness, palpitations, nausea

• Headache → visual symptoms, vomiting, neurological symptoms

• Fatigue → weight loss, fevers, night sweats

P: Provoking or Palliating Factors

What makes the symptom worse or better?

This often provides important diagnostic clues and can help distinguish between competing diagnoses.

S: Severity

How much is this affecting the patient's life?

Consider the impact on:

• Work

• Home life

• Exercise

• Sleep

• Relationships

Remember, severity is not simply a numerical score. It is about understanding the functional impact of the symptom.

Why OTAPS Matters

OTAPS is not intended to replace clinical reasoning.

Instead, it provides a simple structure that helps gather the key information required for most presentations before moving on to more condition-specific questions.

Combined with The Med Den approach of:

1. Defining the symptom

2. Considering the worst-case diagnosis

3. Considering the common diagnoses

4. Identifying the investigations or findings that would change your differential diagnosis

OTAPS provides a practical framework for gathering information efficiently and systematically.

Management Comes From Diagnosis

Many students focus heavily on management plans.

However, management is usually the easy part.

The difficult part is working out what is going on.

If your diagnosis is correct, management often follows naturally.

For example:

• Asthma diagnosed → Asthma treatment pathway

• Pneumonia diagnosed → Antibiotic pathway

• Acute coronary syndrome diagnosed → Emergency referral pathway

This is why The Med Den focuses on clinical reasoning rather than memorising management plans.

The Key Takeaway

The Med Den system is not another history-taking structure.

It is a clinical reasoning framework that sits inside the information gathering stage of the consultation.

While Calgary-Cambridge tells you how to conduct a consultation, The Med Den helps you think about what might be causing the patient's symptoms.

In simple terms:

Calgary-Cambridge teaches you how to ask questions.

The Med Den teaches you why you are asking them.

Happy learning,

Dr Shabir