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A general history is split into 7 main sections
This should be the first symptom the patient gives you:
- "My head's hurting doctor" - headache
- "I can't feel my feet" - loss of sensation in feet
- "My head has fallen off because a youth used his knife to 'blade' me and I'm now bleeding profusely from the neck" - head loss
It doesn't have to be in medical language and it's fine to quote the patient. As long as the person reading/listening understands that this was basically the first thing the patient came in with. An organised patient (and medical student) will give a list of all the problems here.
History Of Presenting Complaint
Essentially this bit is practically the whole of medicine. In medicine you should 'never say never and never say always'. However, all doctors can take a good history of presenting complaing. Otherwise they are not doctors - just people with a lot of medical knowledge. If you cannot extract the appropriate information from a patient, you're little better than somebody who knows nothing and at least they didn't waste time learning stuff they couldn't use.
You will see different styles of history-taking when you hit the wards. Everybody's different but as long as you don't miss the important stuff with each problem, it's fine. Surgeons will often do their histories in a couple of minutes whereas taking a good psychiatric history can take over an hour.
Anywho - pretentious lecture over. Now the stuff that's vaguely useful:
As a medical student, don't pressure yourself too much with time at first - ask open questions.
- An open question is: "Tell me about the pain in your leg"
- Whereas a closed question is: "Is the pain in your leg sharp or dull?"
Admittedly, the former is technically not a question but stop nit-picking you who was thinking that. The first 'question' will often result in the patient giving you everything you need to know about his leg pain (though often it will result in them telling you about their neighbour's dog's gallstones). The second question is good if you specifically need to know about the nature of the pain but just going through a list of questions about the pain makes it likely you'll miss something.
At the start of a history, always keep it open as in your status as incredibly inexperienced, you're less likely to miss something. A particularly useful acronym for any symptom (though it is particularly good for pain) is:
- Site - "Where is the pain?" (obviously not to be used with a symptom like shortness of breath)
- Onset - "When did the cough start?"
- Character - "What was the pain like?"
- Radition - "Did the pain move anywhere?"
- Associated factors - "You say you've blood in your urine. Have you been going more often?"
- Timing and pattern - "Has the weakness stayed the same or did it come on gradually?"
- Exacerbating/relieving factors - "Does anything make it better or worse?"
- Severity - "On a scale of 1-10, where 10 is the worst pain ever and 1 is nothing, how bad is the pain?";"How badly does the tremor affect your day-to-day activity?"
Closed Questions And Diagnosis
Having just told you to ask open questions you also need to ask closed questions once you've identified the patients main problem(s). This is a big deal which is why it is covered in a seperate section on diagnosis.
Past Medical History
The three things to ask are:
- Do you have any long-term illnesses like asthma, diabetes or hypertension?
- Have you ever been admitted to hospital?
- Have you had any operations?
(Incidentally, just because they have not been admitted to hospital, doesn't mean they haven't had day operations - which includes abortions i.e. pretty important.)
Ask about first-degree relatives (parents, children and siblings). Which you ask about depends on the age of the patient. Asking a child about his children's health is not appropriate. Asking a young woman about her children isn't that appropriate if you're looking for risk factors for breast cancer. Ask about:
- Parents - how old are your parents? Do they have any long-term illnesses?/How old were you parents when they died? How did they die?
- Don't assume that elderly patients' parents are dead. There is nothing wrong with asking, "are your parents still alive?"
- Siblings - much the same questions as with parents. More useful the older the patient is.
- Children - occasionally useful but usually not.
Broadly speaking, split into two sections: accomodation and substances.
You want to get a basic idea of the patient's living arrangements. This is especially important in geriatrics as it often involves a number of people but it is still important in every patient. You need to ask about:
- who the patient lives with.
- type of house (bungalow/semi-detached/terraced etc.) - especially important if mobility is limited.
- occupation - occupational diseases are important to identify.
Alcohol, Smoking and Illicit drugs'. It is important to ask about these and know how to ask about them.
It's not enough to just ask 'how much?' because you'll get a vague answer like 'occasionally' or 'moderately' which tells you absolutely nothing. Pin the patient down to a specific amount in a specific timeframe.
- How much per night?
- How much at weekends?
- Every night?
- Every weekend?
- Is it roughly the same from week to week?
Thus you should get a number of units per week.
Even more so than alcohol, it is important to get the right amount in pack years. For those of you who don't smoke, there are '20 cigarettes in a pack. One "pack year" is smoking a pack a day for a year. So if you smoke 10 a day for 10 years, that's 5 pack years i.e. half a pack a year for 10 years. It isn't an exact equation but so long as the number is roughly right, it should be fine. So ask:
- Do you smoke?
- If no, ask have you ever smoked? - thus, they are either a current smoker, ex-smoker or never-smoked. 'Non-smoker is not good enough!
- If yes, ask the same sort of things you'd ask a current smoker.
- What do you smoke?
- How many/much do you smoke a day? depending on what they smoke.
- How old were you when you started smoking?
- Have you always smoked about the same amount?
- For ex-smokers when did you give up?, usually answered with when I got into hospital, doctor. Smartarses.
Much the same as smoking and alcohol, really. Most patients will understand that you need to ask the question, even to the most unlikely people. Some will be offended but it very rarely happens and if they are then so be it. It's better that you ask than you're negligent and it is negligent not to ask. So:
- Have you ever taken any illicit substances or recreational drugs, prescription or otherwise?
- Have you ever had any problems with addiction? - this is because being on prescription methadone might not get a response from the first question but it is important to identify.
If the response is yes to either of these questions:
- What do you take?
- How often/much?
- How do you take the drugs? (injection/smoking/tablet)
The second question is not all that useful as most people haven't taken street drugs so quantities don't mean anything.
This is generally medications. Illicit drug use should be asked in the section above. Generally, the patient will be on very few drugs or you'll get, "sorry, I have no idea". In hospital, you should just be able to pick up the drug card. You should get three things: generic name, dose (both amount and regularity) and route of administration:
This is the name that you should find on the drug card. For instance, clopidogrel is an antiplatelet drug that is also known as Plavix. Plavix is its trade name which is used for marketing the drug and often patients will know this and not the generic name.
Amount in the appropriate units (micrograms, milligrams, kilograms - whatever)
How often? This will usually be given in shorthand (od - once a day; bd - twice a day; tds - three times; qds - four times; prn - as required)
This is how you get your drug into the patients. Again, there'll be shorthand on drugs (iv - intravenous; im - intramuscular; sc - subcutaneous; po - orally; pr - rectally, per rectum; s/l - sublingual; pv - vaginal, per vaginam). If you come across more, feel free to add them.
Basically, you run through specific symptoms in each system. It occasionally brings something up that the patient has forgotten from their past medical history. I'll write a list, soon but for now, just go through each system. If you have trouble remembering every system, think about your course and use that order. Alternatively, just go from top to bottom of the body.
This is important - especially penicillin allergy. Although epipens (used to treat anaphylaxis) are there, you don't want to have to use one if you don't have to. Finally, don't put no allergies. Write no known allergies because really, you can't claim to know if a patient has no allergies.