Summary A 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. When you fill out forms at your doctor’s office, do you wonder why it matters whether or not your grandmother had high blood pressure or diabetes? Your doctor also asks you questions like this. Why is it important? Your
medical history includes both your personal health history and your family health history. Your personal health history has details about any health problems you’ve ever had. A family health history has details about health problems your blood relatives have had during their lifetimes. This information gives your doctor all kinds of important clues about what’s going on with
your health, because many diseases run in families. The history also tells your doctor what health issues you may be at risk for in the future. If your doctor learns, for example, that both of your parents have heart disease, they may focus on your heart health when you’re much younger than
other patients who don’t have a family history of heart disease. If it’s possible, every adult should know their family health history. You may or may not already know some information about conditions that affected different family members. Even if you think you do, double-check
what you know. Find out even more about as many blood relatives as you can, and remember to include half-sisters and brothers. You should not include people who are not blood relatives, such as: Make sure to write down what you learn, in case you forget details over time. You’ll also be able to add to the information you already have. Make sure to share the information with your siblings, children, or grandchildren, as they get older. To get started, call your relatives, or ask them in person about your family health history. Let your relatives know you’re not being nosy, but just
want to gather details that could keep you and other family members healthy. You can offer to share what you learn, so that everyone can benefit from your research. You’ll want to ask about common chronic (ongoing) health conditions. Find out how old each person was when they learned about their condition. You may want to start by asking about these common family health problems: You’ll need to know
the health history of relatives who have died, too. If you have access to death certificates or medical records, you can find out the cause of death and how old they were, but living relatives may know the details. If You’re AdoptedIf you were adopted, you may not know anything about your birth parents’ health history. If that’s the case, a big chunk of your medical history is a question mark. You may wonder if you’re at risk for heart disease, cancer, or other diseases that run in families. Rules vary by state, but most adopted people are able to access details about their birth parents’ family medical history once they become adults. Such information may be found through a state’s child welfare agency or the department that assists with adoptions. How Your History Keeps You HealthyOnce you find out your medical history, you can make powerful choices for yourself. If you learn, for example, that heart disease runs in your family, you may decide to make lifestyle changes that could lower your risk, such as quitting smoking, losing weight, or getting more exercise. Your doctor may also use the information to give you screening tests, which might catch a disease, such as cancer, early. There are lots of ways your medical history can put you and your doctor in better control of your health. Which of the following is usually included in a medical history?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.
What are the 4 components of medical history?In general, a medical history includes an inquiry into the patient's medical history, past surgical history, family medical history, social history, allergies, and medications the patient is taking or may have recently stopped taking.
What information is contained in the medical record?Medical charts contain documentation regarding a patient's active and past medical history, including immunizations, medical conditions, acute and chronic diseases, testing results, treatments, and more.
What is included in medical history quizlet?allergies, immunizations, childhood diseases, past medication, previous illnesses, surgeries, and hospitalizations.
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Which of the following is usually contained in the first part of the medical history
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