History Taking

Taking a Medical History the Proper Way

History taking in medicine is the most important aspect of the medical examination. You can retrieve more than 90% of your diagnoses through a good and effective history taking method. Here we will describe a concise and easy method to take a history.

Medical History Taking Process:

Identifying Data

What is your name ?

What is your age?

What is your occupation?

What is your marital status?

Chief Complaint

What is the reason that you are here today?

History of Present Illness

This can be done through a simple mnemonic, OPQRS, or just through who, what, where, when, why, how, etc...

O - Onset/Course of disease and/or problem - When did this happen? How many times has this happened? How long did it occur each time?

P - Provoke - What causes the problem/symptoms?

P - Point - Can you point to the area of the symptoms? Can you point to the area where it is the worst?

Q - Quality - Can you describe to me the symptoms/pain? What is the quality of the pain, sharp stabbing-like or a dull ache?

R - Radiating - Do the symptoms radiate? Does the pain shoot or transfer to other parts of the body?

S - Setting - Where do the symptoms occur? Work or Home? Where are the symptoms worse, early in the day, or late? When you awake?

S - Severity - How bad are the symptoms? How painful is it? From a scale of 1-10, with 10 being the worse pain you have ever had, where would you rate this?

T - Timing - Are the symptoms constant or intermittent? Does the pain/symptoms fluctuate?

U - Bucket for the rest - Any other symptoms? What else happens when you feel these pains/symptoms? (To pick up any associated symptoms).

V - alleViate - Does anything alleviate the symptoms? Does anything help?

W - Wrong - What do you think is wrong?

X - What are all the treatments and procedures that have been performed in regards to your present symptoms/state?

Past Medical History

(HITS) Surgeries - Hospitalizations - Illnesses - Trauma

Last Meal (if patient might go into surgery soon for the problem)

Allergies

(ART) - Agent that causes the reaction (e.g. Penicillin), Reaction type (e.g. mild rash, anaphylaxis), and Treatments for the reaction if any (e.g. Epi-Pen)

Medical Alert Bracelet - ask about

Medications

(NDFL) Name, Dosage, Frequency, Length of usage

Ask specifically about certain drug families known to cause problems NSAIDS (e.g. for ulcers, kidney issues), steroids, etc..

Herbs and Herbal Medicines - these can interact with many drugs

Traditional Medicines - ask about these, as many people do not believe they are Herbs, etc...

Social History

Smoking (e.g. How many packs per day? How many years? Calculate as Pack-Years, where 1 pack-year is 1 cigarette pack per day per year, such that 2 packs smoked per day per year equals 2 Pack-Years for that individual, if done for 10 years, equals 20 Pack-Years, and so on)

Alcohol (e.g. How many drinks of alcohol do you usually have during a week? Always add 2-4 drinks on what they say? Do the CAGE questionnare if worried)

Recreational drugs (e.g. Have you recently had any cocaine? marihuana? heroin?)

Coffee (e.g. How many cups a day?)

Diet (e.g. Home cooked meals? Fast food?)

Lifestyle (e.g. Do you exercise? Drive to work? Walk home?)

Family History

May have to draw a pedigree to delineate any type of inheritance traits (e.g. X-linked or autosomal dominant vs. recessive)

Arthritis

Atopy (asthma, allergic rhinitis, eczema)

Diabetes

Heart Disease

Cancer

General Review of Systems

General: How is your general health like?

Any changes in your (seaw) Sleep? Energy level/Fatigue? Appetite? Weight?

Any (cfs) Chills, Fevers, Sweats?

Any Nausea, Vomitting (bilious, feculent, blood), Diarrhea, Malaise?

Any Headaches, Dizziness, Lightheadedness, Fainting spells, Life stresses?

Any Muscle or Joint Pains? Any Pain at all?

Specific Aspects that may be added to a History:

Occupational History

Legal History

Psychiatric History