Taking a Medical History:A surprisingly complicated procedure

Sean Reed, M.D.Assistant Professor

Department of Family Medicine

Content of Medical History

• Chief Complaint

• History of Present Illness

• Past Medical History

• Family History

• Social History (Patient Profile)

• Review of Systems

Feel like you are getting only half of a very complicated story

You’re not at all sure where the story is going and you are afraid of wasting time

You understand what the patient is saying, but you are not sure what is going on

Chief Complaint (CC)

• Patient’s main reason

to seek care

• Agenda setting

• Hidden agendas

Chief Complaint:

“My wife made the appointment for me”

“I can’t find my penis”

“Cell phone injury”

… Family history of diabetes

… Congestive heart failure

… Five sutures to the forehead and a tetanus shot

“Is there something in particular that you are worried about?”

SKILLS DONE WELL

OK, COULD BE BETTER

NOT DONE OR DONE POORLY

NOT APPLICABLE

1. Introduces self and explains purpose of interview.

3 2 1 N/A

2. Attends to the patient’s comfort and privacy.

3 2 1 N/A

3. Allows patient to describe the illness/chief complaint.

3 2 1 N/A

4. Uses the following techniques effectively (Note: you don’t have to use them all!) Open-ended questions Reflection/Repetition Clarification Silence Facilitators (nods, uh-huh, etc…) SummationOVERALL USE OF INTERVIEWING TECHNIQUES

3333333

2222222

1111111

N/AN/AN/AN/AN/AN/AN/A

5. Balances listening with structure. 3 2 1 N/A

6. Follows up on cues and vague statements.

3 2 1 N/A

7. Attends to patient’s nonverbal cues. 3 2 1 N/A

8. Responds empathetically and supportively.

3 2 1 N/A

9. Closes interview appropriately. 3 2 1 N/A

Power Tools/Techniques BENEFITS:Body posture and movementsEye contactFacial expressionInflection, tone of voice and rate of speechTouchSpace between doctor and patient

FOUCS:FacilitationsOpen-ended questionsClarification and directionUnderstanding by checkingSurveying problems

AVOID:leading questionsmultiple questions

SUMMARIZE:Feedback to patient your understanding of story

If you are lostIf you are uncertainIf done/transition

Getting started

• What brings you in today?

• How can I try and help today?

• What would you like to discuss today?

• I see that you have told the nurse…

History of Present Illness (HPI):

Physician-centered framework: 7 Symptom characteristics

– Location– Quality– Severity– Timing– Setting/context– Modifying factors– Associated symptoms

Pain History (“OPQRST”):

• Onset and Occasion when symptom first was noticed

• Provocative and Palliative factors• Quality and/or Quantity of symptom• Region of body and Radiation to other areas• Severity of symptom (0 to 10 scale, if

applicable) and associated Symptoms• Time (duration) and Temporal associations

(what is going on when symptom occurs)

Past Medical History

• Major illnesses

• Hospitalizations

• Surgeries

• Significant injuries

• Medications

• Allergies

• Immunizations

• Transfusions

• Gynecologic and

obstetric history

• Psychiatric history

Past Medical History

Medical Illnesses – identify chronic illnesses

Hospitalizations - approximate dates

Surgeries - approximate dates/reasons(ex: hysterectomy – benign or malignant?)

Significant injuries

Past Medical History

Medications– name, dosage, frequency, reason– OTC, herbal, vitamins, supplements

Other alternative medicine therapiesAllergies

– describe reaction

Immunizations TransfusionsGyn and Ob history

– LMP, birth control use

Past psychiatric history

Family History

• Current health of family• Specific familial diseases• Other family members

with similar illnesses

“Patients rarely volunteer a family history of mental illness or addiction”

Social History / Patient Profile

How do lifestyle or personality traits:• Contribute to causality of illness?• Aggravate or limit severity of

illness• Interfere or help with getting well• The “usual day”

Social History/Patient Profile

• Demographic information• Occupational and educational history

– Military

• Travel history– Refugee history

• Health Habits– Smoking, Alcohol, Drug use– Exercise– Diet

• Sexual history• Significant relationships• Spiritual, cultural and health beliefs

What do you do for a living?

What do you do for fun?

Review of Systems

• Uncover other medical problems

• Identify symptoms that may be related to presenting symptoms

• Move from general to specific questions– Positive responses need further

clarification

SUMMARYInterviewing gems

Is there something in particular that you are worried about?What do you do for a living?What do you do for fun?

Don’t forget your power tools / techniques

7 Symptom characteristics– Location Setting/context– Quality Modifying factors– Severity Associated symptoms– Timing

Summarize the visit

Ask for questions

Describe next stepinvolve patient, if decision needed

Thank you for listening