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My Health Record brings together health information from you, your healthcare providers and Medicare. This can include details of your medical conditions and treatments, medicine details, allergies, and test or scan results, all in one place. Healthcare providers like doctors, specialists and hospital staff may also be able to see your My Health Record when they need to, including in an accident or emergency. See Digital Health for more information about what's in My Health Record.
The remainder of the history is obtained after completing the HPI. As such, the previously discussed techniques for facilitating the exchange of information still apply. Past Medical History: Start by asking the patient if they have any medical problems. If you receive little/no response, the following questions can help uncover important past events: Have they ever received medical care? If so, what problems/issues were addressed? Was the care continuous (i.e. provided on a regular basis by a single person) or episodic? Have they ever undergone any procedures, X-Rays, CAT scans, MRIs or other special testing? Ever been hospitalized? If so, for what? It's quite amazing how many patients forget what would seem to be important medical events. You will all encounter the patient who reports little past history during your interview yet reveals a complex series of illnesses to your resident or attending! These patients are generally not purposefully concealing information. They simply need to be prompted by the right questions! Past Surgical History: Were they ever operated on, even as a child? What year did this occur? Were there any complications? If they don't know the name of the operation, try to at least determine why it was performed. Encourage them to be as specific as possible. Medications: Do they take any prescription medicines? If so, what is the dose and frequency? Do they know why they are being treated?* Medication non-compliance/confusion is a major clinical problem, particularly when regimens are complex, patients older, cognitively impaired or simply disinterested. It's important to ascertain if they are actually taking the medication as prescribed. This can provide critical information as frequently what appears to be a failure to respond to a particular therapy is actually non-compliance with a prescribed regimen. Identifying these situations requires some tact, as you'd like to encourage honesty without sounding accusatory. It helps to clearly explain that without this information your ability to assess treatment efficacy and make therapeutic adjustments becomes difficult/potentially dangerous. If patients are, in fact, missing doses or not taking medications altogether, ask them why this is happening. Perhaps there is an important side effect that they are experiencing, a reasonable fear that can be addressed, or a more acceptable substitute regimen which might be implemented. Don't forget to ask about over the counter or "non-traditional" medications. How much are they taking and what are they treating? Has it been effective? Are these medicines being prescribed by a practitioner? Self administered? * You'll be surprised to learn how many patients don't know the answers to these questions. Encourage them to keep an up to date medication list and/or write one out for them. When all else fails, ask the patient to bring their meds with them when they return or, if they are in-patients, see if a family member/friend can do so for them. Allergies/Reactions: Have they experienced any adverse reactions to medications? The exact nature of the reaction should be clearly identified as it can have important clinical implications. Anaphylaxis, for example, is a life threatening reaction and an absolute contraindication to re-exposure to the drug. A rash, however, does not raise the same level of concern, particularly if the agent in question is clearly the treatment of choice. Smoking History: Have they ever smoked cigarettes? If so, how many packs per day and for how many years? If they quit, when did this occur? The packs per day multiplied by the number of years gives the pack-years, a widely accepted method for smoking quantification. Pipe, cigar and chewing tobacco use should also be noted. Alcohol: Do they drink alcohol? If so, how much per day and what type of drink? Encourage them to be as specific as possible. One drink may mean a beer or a 12 oz glass of whiskey, each with different implications. If they don't drink on a daily basis, how much do they consume over a week or month? Other Drug Use: Any drug use, past or present, should be noted. Get in the habit of asking all your patients these questions as it can be surprisingly difficult to accurately determine who is at risk strictly on the basis of appearance. Remind them that these questions are not meant to judge but rather to assist you in identifying risk factors for particular illnesses (e.g. HIV, hepatitis). In some cases, however, a patient will clearly indicate that they do not wish to discuss these issues. Respect their right to privacy and move on. Perhaps they will be more forthcoming at a later date. Obstetric (where appropriate): Have they ever been pregnant? If so, how many times? What was the outcome of each pregnancy (e.g. full term delivery; spontaneous abortion; therapeutic abortion). Sexual Activity: This is an uncomfortable line of questioning for many practitioners. However, it can provide important information and should be pursued. As with questions about substance abuse, your ability to determine on sight who is sexually active (and in what type of activity) is rather limited. By asking all of your patients these questions, the process will become less awkward. Do they participate in intercourse? With persons of the same or opposite sex? Are they involved in a stable relationship? Do they use condoms or other means of birth control? Married? Health of spouse? Divorced? Past sexually transmitted diseases? Do they have children? If so, are they healthy? Do they live with the patient? Family History: In particular, you are searching for heritable illnesses among first or second degree relatives. Most common, at least in America, are coronary artery disease, diabetes and certain malignancies. Patients should be as specific as possible. "Heart disease," for example, includes valvular disorders, coronary artery disease and congenital abnormalities, of which only coronary disease has genetic implications. Find out the age of onset of the illnesses, as this has prognostic importance for the patient. For example, a father who had an MI at age 70 is not a marker of genetic predisposition while one who had a similar event at age 40 certainly would be. Also ask about any unusual illnesses among relatives, perhaps revealing evidence for rare genetic conditions. Work/Hobbies/Other: What sort of work does the patient do? Have they always done the same thing? Do they enjoy it? If retired, what do they do to stay busy? Any hobbies? Participation in sports or other physical activity? Where are they from originally? These questions do not necessarily reveal information directly related to the patient's health. However, it is nice to know something non-medical about them. This may help improve the patient-physician bond and relay the sense that you care about them as a person. It also gives you something to refer back to during later visits, letting the patient know that you paid attention and really remember them. Military Service: For obvious reasons, serving in the armed forces can be an important period in someone's life. In addition, inquiring about physical trauma, mental health issues (PTSD, depression, substance abuse), and unusual exposures (toxins, infections) may reveal important information. In recounting their history, patient's frequently drop clues that suggest issues meriting further exploration. If, for example, they are taking anti-hypertensive or anti-anginal medications yet made no mention of cardiac disease, additional history taking would be in order. Furthermore, if at any time you uncover information relevant to the chief complaint don't be afraid to revisit the HPI.
Introduction
The key skills to help establish the underlying cause of a patients' symptoms (the diagnosis) is based on talking to the patient (the history), examining the patient (the examination) and requesting tests like bloods and x-rays (the investigations). The information gathered from the history and examination is used to form a hypothesis of the possible underlying diagnosis. Investigations can then be used to either confirm or refute this diagnosis. Some diagnoses can be made just by talking to a patient, while others are reliant on a specific test. As a medical student, student nurse, physician associate, or allied health professional you learn the art of taking a formal history, examining a patient, and interpreting investigations. The history is considered the most important aspect of the interaction between patient and doctor. It is the cornerstone of the doctor-patient relationship and relies on good communication skills. Most information about a patient can be determined by the history alone. Here, we describe the basic structure to history taking in medicine that is used by all clinicians to gain information from a patient about their condition. History structure
The history has a well-formulated structure to help determine the patient's problems in a logical order and to establish any other relevant information (i.e. previous medical problems, medications). It also helps to sign-post key parts of the history and provides sub-headings when presenting information to another medical professional (another core component of medical practice). The basic structure of the history is as follows:
Presenting complaint
An example of a typical PC would be abdominal pain or headache. The PC should capture key information about the patient that helps to focus the history including age, sex and timing of the complaint. This information helps to focus the potential list of causes. For example; “88 year old female presenting with a 1 month history of abdominal pain” “23 year old male student presenting with a 12 hour history of headache and fever” “56 year old male heavy smoker presenting with a single episode of coughing up blood (haemoptysis)” History of presenting complaint
You should ask a series of both open and closed questions to further clarify the problems being faced by the patient. Key questions may include: “Could you tell me more about this symptom?” “How long has the symptom been affecting you?” “What makes the symptom worse?” “Is it associated with any other symptoms?” In general, the HPC can be targeted depending on the presenting problem. You always need to determine the chronicity and associated features of any problem. If it is pain, you need to take a pain history. If the problem is related to a particular system (i.e. heart or lung), you need to ask system-specific questions. Duration of symptomsIt is essential to determine when the problem started, how long it has been going on for, whether it is constant or fleeting, and whether it has been worsening or getting better. Associated symptomsAlways ask about associated symptoms such as nausea and vomiting, breathlessness, or fever. As you learn more about clinical medicine you will learn what the important questions are to ask. Pain history (SOCRATES)Pain is an extremely common symptom, and it is essential that all clinicians can take a good pain history from a patient. The key parts to a pain history can be remembered by the mnemonic SOCRATES.
System-specific questionsThese are groups of questions that should be asked when a patient presents with a particular complaint. They can be grouped based on organ systems (e.g. cardiovascular, respiratory). These are discussed more in our other clinical history notes. Past medical history
It is important to determine each problem, when it started, the treatment required and whether there is any ongoing follow-up. Two examples are shown below: Myocardial infarction (heart attack):
Gallstones:
It is often useful to ask the patient specifically about a number of common conditions using the mnemonic MJTHREADS:
Drug history
For all medications you need to establish the name, dose (i.e. mg/mls/mcg), frequency (i.e. once a day, once a week), and route (oral, intramuscular, intravenous). The four things to ask about:
Always establish concordance (i.e. is the patient actually taking their medications), any side-effects and any recent changes (e.g. medications that have stopped or been started or dosing changes). Family history
When gathering a family history, you need to find out the condition affected by the relative, the age at which it was diagnosed and the relationship to the patient. A family tree can be used to help represent this information. Examples:
Social history
The purpose of a social history is two-fold. First, you need to find out relevant information about home and domestic activity, job and financial security, travel, smoking and alcohol consumption. Second, you need to consider the effects of their medical conditions on these social issues (i.e. poor mobility due to heart failure, need carers due to dementia). The key parts of the social history can be remembered using the mnemonic LOLAS DIET:
Activities of daily living (ADL)This refers to what the patient can do for themselves and how any illnesses may be affecting them. It is important to determine information such as whether they can wash and dress, can they go to the bathroom by themselves, do they have any carers, do they walk with any sticks or frames. In older patients, the Rockwood Clinical Frailty Scale should also be used to determine how 'frail' a patient is based on their ability to complete personal or domestic tasks. This is based on a patients' capability two weeks ago and may need discussion with the next of kin or carer. The clinical frailty score is a reliable predictor of outcomes in patients' presenting through emergency services. The scale runs from 1 (very fit) to 9 (terminally ill). Alcohol consumptionThis needs to be quantified based on a weekly average of alcohol intake. The national advice for both men and women is to not drink more than 14 units/week on a regular basis, with several alcohol-free days and a max of 3-4 units in any one day. Screening alcohol dependenceAlcohol abuse and dependency are major issues. A variety of questionnaires are available to screen for the risk of harmful alcohol use. This has two major benefits:
Two commonly used tools are: CAGE is a series of 4 screening questions that are used to determine the risk of excessive drinking or alcoholism. Each question equals 1 point.
A score of ≥2 should warrant further assessment for alcohol dependence. In the inpatient setting, this would warrant assessment for alcohol withdrawal AUDIT is a more detailed questionnaire that was developed by the World Health Organisation (WHO). It consists of 10 questions with a score of 0-4 per question. It should start by saying 'Now I am going to ask you some questions about your use of alcoholic drinks during this past year' that is followed by each question as written. A score ≥8 is an indicator for harmful alcohol use. Smoking historySmoking history is described in the number of pack years. A single pack-year is equivalent to smoking 20 cigarettes a day for a whole year. Therefore, if someone has smoked 20 cigarettes a day for 40 years, they have a 40 pack-year smoking history. This can be explained by the following formula: Pack years = (Cigarettes smoked per day / 20) x Number of years Systems review
The systems review can be completed at any point during the consultation but is usually completed at the end or following the history of presenting complaint. It is important to ask brief, closed questions, to ensure you cover the major symptoms in a timely fashion. However, a positive response should be further investigated fully like in the history of presenting complaint. The best way to approach the systems review is to start by asking four general questions, and then ask short closed questions from head-to-toe. The four general questions are useful to screen for malignancy or chronic infections. The four general questions include:
The short, closed questions, from head-to-toe may be as follows:
Ideas, concerns, expectations
‘Do you have any idea about what could be going on?’ Ideas refers to the patients' own thoughts about what the problem could be and helps to guide your own diagnostic process. Concerns‘Is there anything which is concerning you at the moment?’ It is good practice to address any concerns a patient has during the consultation. It also helps to provide reassurance and offers time for the patient to ask any questions they might have. Expectations‘Was there anything you were hoping for from our discussion today?' It is important to establish the patients' expectations during or at the end of the consultation. For example, a patient presenting with a viral illness may be expecting to get antibiotics. Have comments about these notes? Leave us feedback |
What information is needed when taking a patient history?
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