SummaryA medical history is a report that includes information gained from a patient's medically relevant recollections (e.g., symptoms, concerns, past diseases) and questioning regarding their concerns. While a physician should generally take their time to take a thorough history, situations such as medical emergencies may only provide enough time for a short history to avoid delaying potentially vital interventions. Because it takes some practice to distinguish between important and irrelevant information, it is best to follow a set protocol in the beginning. Medical history provides the basis on which diagnosis and treatment are developed. An uninterrupted setting in a quiet room with only the examiner and the patient present ensures that patients can openly discuss their concerns and reinforces the patient-physician relationship. This article provides an overview of what a general medical history should cover. Depending on the patient's concerns, additional and/or more targeted questions may be appropriate. See the articles “Pediatrics: history and physical examination” and “OB/GYN: history and physical examination” for further details about those patient groups. Show
Basics of history takingA thorough medical history is the basis for diagnosis. At the beginning of your clerkship, it is recommendable that you take a history according to a standardized scheme that covers the key elements. The more experience you acquire in taking a patient's medical history, the more you will be able to readily determine what areas to focus on. It may be helpful to begin the interview with a few general questions about the patient's life, e.g., profession and familial status, as they may serve as an icebreaker. Chief concernHistory of present illnessTo remember the key points for evaluating pain, the most common reason for patients to see a physician, recall the mnemonic LIQOR AAA. Another useful mnemonic to help remember the key points of HPIis COLD REARS SIT. Past medical historyFamily historySocial historyReview of systems (ROS)You do not have to ask every question; tailor the questionnaire to the patient and their chief concern (e.g., sexual history may not be relevant if the reason for the visit is an ankle fracture follow-up). Use your best judgment about what to ask and what to leave out, keeping in mind you generally have no more than 10–15 minutes per interview. Constitutional symptomsEyeHead and neckEar, nose, mouth, and throat (ENT)CardiovascularRespiratoryGastrointestinalGenitourinaryUrinaryGenitalMusculoskeletalIntegumentary systemSkin and hairBreastNeurologicalSee neurological examination for more information. PsychiatricSee mental status examination for more information. EndocrineHematologic/lymphaticVascularAllergic/immunologicAt the end of history taking, ask the patient for their primary care physician (PCP). Potential previous findings can be obtained from their PCP. Furthermore, interim or discharge reports are sent to the PCP. Adult Review of Systems (ROS)OverviewThe review of systems (or symptoms) is a list of questions, arranged by organ system, designed to uncover dysfunction and disease within that area. It can be applied in several ways:
So, what's the best way to use the ROS? I have always been dubious of its utility as a broadly applied screening tool. Using it in this fashion makes sense if the following hold true:
Unfortunately, aside from a few specific screening tools (e.g. depression), there is little evidence to support these assumptions. In fact, positive responses to a screening ROS are often of unclear significance, and may even create problems by generating a wave of additional questions (and testing) that can be of low yield. For these reasons, many clinicians (myself included) favor a more targeted/thoughtful application of ROS questions, based on patient specific characteristics (e.g. age, sex) and risk factors (e.g. history of diabetes → perform cardiovascular ROS). This strategy, I think, is both more efficient and revealing. As you gain experience, you can make an informed decision about how you'd like to incorporate the ROS into your overall patient care strategy. It's important to recognize that positive responses will require follow-up questioning. For example, if a patient responds “yes” to an ROS question about chest pain, you would then need to ask additional questions to further define the core dimensions of this symptom. The OLD CARTS mnemonic (or other similar frameworks) provide structure for these follow-up questions. In addition, for a patient with chest pain, an assessment of cardiac risk factors and an organized search for exam findings indicative of vascular disease (e.g. elevated BP, diminished peripheral pulses, etc.) would be relevant. In addition to also consider non-cardiac etiologies (e.g. pulmonary, GI, MSK, etc.). On the basis of the sum of this data, the clinician can come to an informed conclusion about the importance/cause of this patient's chest pain (e.g. angina, heartburn, pulmonary embolism), and use this to guide their subsequent decision making. Guide To Using This ROSThere is no ROS gold standard. The breadth of questions included is somewhat arbitrary, based on the author's sense of the most commonly occurring illnesses and their symptoms. There is planned redundancy, as the same symptoms often apply to multiple organ systems. Feel free to edit/adapt to fit your clinical needs. Realize that exotic or regional illnesses might require other ROS questions. In addition, some sub-specialty areas use an expanded ROS, specific to the conditions that they evaluate and treat. I've added a few novel features, designed to clarify why an ROS question is asked and in what direction the response should lead. These include:
I would like to highlight several important limitations:
Clicking on the main categories reveals a list of broad questions. Clicking on any of these symptoms questions reveals a list of common disorders that might be at the root cause of the particular symptom. GeneralVisionHead and Neck (H&N)PulmonaryCardiovascular (C/V)GastrointestinalGenito-UrinaryHematology/OncologyOb/Gyn/BreastNeurologicalEndocrineInfectious DiseasesMusculoskeletalMental HealthSkin and HairFinally, we’ve developed the on-line Web App Digital DDx, which provides a much more extensive diagnostic support tool. ROS questions are provided, along with a clickable tree of diagnoses to aid in the interpretation of responses. It also contains many other features that highlight the connections between organ based symptoms and specific disorders. Which of the following is the most appropriate action in order to make a correction when an error has been made in the chart quizlet?Which of the following is the most appropriate action to make a correction when an error has been made in the chart? draw a single line through error.
Which of the following is the most appropriate action of the medical assistant when asking a patient about sensitive topics?Which of the following is the most appropriate action of the medical assistant when asking a patient about sensitive topics such as alcohol or drug use? Wait until a good rapport with the patient is established before asking sensitive questions.
What is the best description of a review of systems?The Review of Systems (ROS) is an inventory of the body systems that is obtained through a series of questions in order to identify signs and/or symptoms which the patient may be experiencing.
Which of the following is usually included in medical history?A record of information about a person's health. A personal medical history may include information about allergies, illnesses, surgeries, immunizations, and results of physical exams and tests. It may also include information about medicines taken and health habits, such as diet and exercise.
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