The Medical History Flashcards
8 stages of the history
1 - presenting complaint 2 - HPC 3 - PMSH 4 - DH 5 - FH 6 - personal and social history 7 - systems review 8 - ICE
Presenting Complaint
This is the main reason for the patient’s attendance to hospital/GP surgery and should be
recorded in the patient’s own words.
History of Presenting Complaint
This is a list of the main symptoms, either volunteered by the patient or elicited from them during the consultation.
For each, gather information about:
• body location
• quality and severity
• chronology, including when it first began, mode of onset, mode of ending, duration,
frequency, periodicity
• setting (under what circumstances does it take place)
• aggravating and alleviating factors, including treatment
• associated manifestations
• overall course, effect on normal activities
• a review of any other symptoms with regard to the body systems under
consideration
• any previous history of similar symptoms
It is also important to ask about any relevant risk factors relating to the presenting complaint,
e.g. if taking a history from a patient who has presented with chest pain then ask about
smoking, hypertension, high cholesterol, diabetes, family history of heart disease.
Past medical and surgical history
This is to gather information about the person’s past illnesses and treatment. This will include information about:
• previous hospital admissions
• past operations or investigations
• major illnesses; rheumatic fever, diabetes, heart disease, jaundice
• accidents and injuries
MJ THREADS
MI Jaundice TB Hypertension Rheumatic fever or rheumatoid arthritis Epilepsy Asthma Diabetes Stroke
Drug history
This is to establish:
• medication the patient is taking (prescribed and over the counter)
• medication that the patient is known to be sensitive to
This information is needed because:
- medication may be the cause of the presenting problem
- current medication may preclude the use of other medications
- if a person is admitted to hospital they may need to continue current medication
• it provides an opportunity to review the need for taking medications and to find out
whether the person is actually taking them
• the patient may be suffering from side effects
Family history
The family history should include:
- causes and age of death of parents
- details about the health of siblings and children
- details about any health problems or conditions within the family.
Personal and social history
This documents factors in the person’s lifestyle, environment and personal habits which can
put them at risk from illness or have a bearing on established disease. This is an opportunity
to discuss how the person maintains their health (as opposed to discussing illness) and to consider whether there is a need for primary or secondary prevention.
Primary prevention is the prevention of disease, for example, by health education or immunisation.
Secondary prevention is the prevention of the effects of disease, by early treatment or prevention of worsening the disease, e.g. by removing the causative agent (e.g. by stopping smoking or
losing weight after the development of angina).
Illness may be related to occupation, to environment, or to being unemployed. Home
responsibilities may preclude admission to hospital. Some social security payments are
stopped during hospital admission. Recent or past travel abroad may have important implications.
Information to be gathered can include: • general well-‐‑being • alcohol, smoking, recreational drug use • HIV risk factors • housing • family relationships and support • Any carers/district nurse/ social worker input • occupation and job security • social or financial problems
It is important to bear in mind that certain aspects of social history can be private and some patients may find this intrusive. You are reminded to be mindful of this, and to maintain an open and non-‐‑judgemental attitude.
Systems Review
The ‘systems review’ is a traditional comprehensive sweep of all bodily systems, to identify any symptoms which may otherwise be missed. Symptoms which are important in making
the diagnosis may only come to the surface at the end of a consultation – either because they have been forgotten or considered trivial by the patient, or even because the patient has been
particularly worried (sometimes known as the ‘by the way, doctor’ or ‘hand-‐‑on-‐‑the-‐‑door’
symptom).
As a medical student, you do a systems review in order to learn by rote a set of questions for each bodily system, so that you have these at your disposal when required. However, running through the entire list for any given patient would exhaust both of you.
Be selective, i.e. focus on the system(s) relating to the patient’s problem list and include others only if clearly related to the differential diagnosis. Please see the check list below. Remember
to avoid all jargon in your consultation.
what should all history taking end with
asking about the patient’s perspective of their own condition. ICE - ideas, concerns, expectations.
how do you start when presenting a case
- when presenting a case, start with the patient’s age, gender, occupation and marital status.
how do you introduce the social history
- social history - 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?
how to start a history on walking in the room
start - ice breaker, greet with patients full name and check preferred address. introduce yourself with your full name and role and explain the reason for the interview. seek consent and consent to take notes, explain information is passed on to the doctors. check patients comfort and privacy.
first questions to ask once the history taking starts
- ask for reason of their attendence. reflect back. query whether there are other problems, acknowledge and repeat until there are no others. write down each problem and summarise problem list back to the patient.
- ask the patient to tell the story from when it first started. encourage the patient to talk, if you give them space the patient will talk. clarify statements made by the patient.
what happens if the patient tells you something bad has happened to them emotionally
- use empathy - ‘that must be difficult’ ‘i understand’
