CLIN SKILLS: Basic Medical History

Question 1

basic structure of medical interview

Answer 1

• intro + hand hygiene
• PC
• HOPC (WWQQAA + BICE)
• system/s review
• PMHx
• FHx
• DRUGS
• SocHx
• conclusion + hand hygiene

Question 2

intro phase

Answer 2

• hi, I’m Sienna Gauci, a 2nd year medical student from Monash uni and I’ve been asked to take a full medical history
• name + preferred address
• age/DOB
• occupation
• ATSI
• confidentiality (will remain confidential b/w you, me, treating team unless disclosure required by law)
• consent

Question 3

how to ascertain PC

Answer 3

• what brings you in today
• can you tell me more

Question 4

WWQQAA

Answer 4

• where – location (L/R?) and radiation
• when - when it began, circumstances, fluctuation over time, has it happened before
• quality - describe what it feels like
• quantity - rate out of 10
• aggravating and alleviating factors
• associated symptoms

Question 5

BICE

Answer 5

• beliefs on what is causing symptoms
• impact on life
• concerns
• expectations for visit

Question 6

PMHx

Answer 6

• past and current conditions? how long ago and how long did it last? any Tx? any complications?
• SHx: past surgeries? when? why? any complications?
• past or current injuries? have you recovered? any lasting effects?
• hospitalisations: when, why, how long?
• childhood illnesses? any complications?
• immunisations up to date? if not, which ones have you had?

Question 7

FHx

Answer 7

• any FHx of any medical conditions? then ask specifically re: relevant system
• any medical conditions in siblings, parents, children, grandparents? if so, when were they diagnosed? is it well managed? if any have died from a medical condition ask age of death. if suspected genetic disorder, ask about 3 previous generations

Question 8

DRUGS

Answer 8

• Doctor prescribed
• Recreational (smoking/vaping, alcohol, drugs)
• User/OTC e.g. vitamins, painkillers, alternative/herbal medicines
• Gynaecological e.g. contraception, HRT
• Sensitivity: allergies (how serious, nature of response, how are they managing it)

if yes to medications:
- name + route of administration
Reason
- dosage + frequency (inc time of day)
- how long they’ve been taking it for
- compliance
- side effects

Question 9

drugs, alcohol, smoking/vaping Hx (+ cage)

Answer 9

drugs
- do you or have you ever engaged in recreational drugs
- name + route of administration
- dosage + frequency
- how long they’ve been taking it for
- side effects

alcohol
- do you regularly drink alcohol? Have you ever had any major drinking habits?
- what do you drink
how much do they drink per session (std drinks) - advice is no more than 4 per session, no more than 10 per week
- how often do they drink
- how long have they been in this habit

smoking/vaping
- do you or have you ever smoked or vaped?
- what do you smoke? cigarettes? vapes? bought? roll your own?
- how much do you smoke per day - calculate pack years if possible (1 pack year = 20 cigs/day)
- how often do you smoke?
- how long have you been in this habit?

CAGE
- ever felt the need to cut down?
- ever get annoyed if ppl tell you to cut down?
- ever feel guilty about drinking too much?
- ever needed an eye opener/woke up and felt the need to drink?

Question 10

SocHx

Answer 10

• exercise
• stress: financial, work etc
• spirituality
• nutrition
• connectedness: social support, hobbies
• environment (living + work): who do you live with
• travel

Question 11

ending the interview phase

Answer 11

• thank Pt for their time
• any questions or anything else to share?
• I will now pass onto GP
• hand hygiene