Take a Medical History

Someone complains of a medical problem (e.g., "I feel tired", "my throat hurts", "I have chest pain", "I feel nauseous", "I can't sleep", "I have a headache", etc.). You want to find out more about this problem to help. This article will give you a systematic way to take a detailed medical history.

Steps

 * 1) Introduce yourself in a friendly manner if you do not know the person. For example, say "Hi! I'm Joe Smith. I would like to ask you a few questions about your illness. Is that OK? You seem to be in pain; how are you feeling?"
 * 2) Get the chief complaint. "What is bothering you right now? how can we help you?" Clarify if needed. "What are you feeling right now?" Survey for other problems. "What else?" Focus on the most important problem first.
 * 3) Explore the main problem in more detail. This can be summarized by the mnemonic OPQRST:
 * 4) *Onset: "how long has it been going on?"
 * 5) *Palliation/Provocation: "what makes it better or worse?"
 * 6) *Quality: "what does it feel like?"
 * 7) *Region/Radiation: "where is the pain? does the pain travel anywhere?
 * 8) *Symptoms/Severity: "what other feelings or sensations do you get? how bad is the headache?"
 * 9) *Timing: maintain the narrative thread. "What happened first? ...then what?..." Find out the context of the medical problem. " "Is the pain continuous, repeating, or sporadic?"
 * 10) Gather the past medical history:
 * 11) *Tell me about the past hospitalizations and surgeries.
 * 12) *What medical problems or illnesses have you had in the past? any injuries?
 * 13) *What medications are you taking?
 * 14) *Any allergies?
 * 15) Gather a family history: "Please tell me about any illnesses that may run in your family. Has anyone else in your family ever had problems like yours?"
 * 16) Gather a social history:
 * 17) *Do you drink, smoke, or use other drugs?
 * 18) *Are you having sex with anyone? How many partners?  Men, women, or both?  Do you use protection?  All of the time?
 * 19) *With whom do you live?
 * 20) *What do you do for work?
 * 21) *Whom can you turn to for support?
 * 22) Review of Systems: Screen for symptoms in each body system that have not already been discussed.
 * 23) *Skin: any skin problems? rash? itch? sores? moles?
 * 24) *Eyes: eye problems? vision loss? itchy eyes? blurry vision? double vision?
 * 25) *Ears, nose, mouth, sinuses, and throat: any trouble with your hearing, ears, mouth, sinuses, or throat?
 * 26) *Lungs: any lung or breathing problems? coughs? chest pain?
 * 27) *Heart: heart problems? racing heart? skipping beats?
 * 28) *Digestive: stomach problems? stomach pain? nausea? vomiting? diarrhea? constipation? bloating? blood in stool?
 * 29) *Genitourinary: trouble with urinating? unusual color or smell? sexual problems?
 * 30) *Hematologic: easy bruising or bleeding?
 * 31) *Endocrine: feeling too cold or too hot compared to others? excessive thirst, hunger, or urination?
 * 32) *Musculoskeletal: problem with your joints or muscles, such as pain, swelling, weakness?
 * 33) *Neurologic: weakness, numbness, or tingling in arms or legs? problem with walking or balance? memory problems? headaches? seizures?
 * 34) *Psychiatric: anxiety? depression? suicidal or homicidal urges? repetitive thoughts or acts?

Tips

 * Try to gather a medical history efficiently. Focus on the main problem and don't feel compelled to ask every single question on the list.
 * It is very important to establish a good rapport in order to take a good medical history.

Warnings

 * Be conscious of time constraints. Focus on the most urgent problem.
 * The social history can be very uncomfortable if YOU are uncomfortable. Keep it professional, and feel out the interview to figure out when to ask sensitive issues about drugs and sex (but these are very important)!

Related Tips and Steps

 * How to Summarize Your Own Medical History
 * How to Analyze a Health Problem
 * How to Maintain Emergency Medical Information
 * How to Describe Medical Symptoms to Your Doctor

Sources and Citations

 * http://en.wikipedia.org/wiki/Medical_history
 * http://www.essortment.com/all/personalmedical_rxou.htm
 * http://www.oup.com/uk/orc/bin/9780199550463/ch03_p18to19.pdf
 * http://medinfo.ufl.edu/year1/bcs96/interv/pmh.html
 * http://www.powerbar.com/articles/97/Taking_a_Client%E2%80%99s_Medical_History.aspx