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Taking a Medical History:
A surprisingly complicated procedure
Sean Reed, M.D.
Assistant Professor
Department of Family Medicine
Content of Medical History
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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 understand
what the patient
is saying, but you
are not sure what
is going on
You’re not at all
sure where the
story is going and
you are afraid of
wasting time
Chief Complaint (CC)
• Patient’s main reason
to seek care
• Agenda setting
• Hidden agendas
Chief Complaint:
“My wife made the appointment for me”
… Family history of diabetes
“I can’t find my penis”
… Congestive heart failure
“Cell phone injury”
… Five sutures to the forehead and a tetanus shot
“Is there something in particular that
you are worried about?”
SKILLS
DON
E
WELL
OK,
COUL
D BE
BETT
ER
NOT
DON
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DON
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POOR
LY
NOT
APPLICA
BLE
1. Introduces self and explains purpose
of interview.
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N/A
2. Attends to the patient’s comfort and privacy.
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3. Allows patient to describe the illness/chief
complaint.
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N/A
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5. Balances listening with structure.
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N/A
6. Follows up on cues and vague statements.
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N/A
7. Attends to patient’s nonverbal cues.
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N/A
8. Responds empathetically and supportively.
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N/A
9. Closes interview appropriately.
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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…)
Summation
OVERALL USE OF INTERVIEWING
TECHNIQUES
Power Tools/Techniques
BENEFITS:
Body posture and movements
Eye contact
Facial expression
Inflection, tone of voice and rate of speech
Touch
Space between doctor and patient
FOUCS:
Facilitations
Open-ended questions
Clarification and direction
Understanding by checking
Surveying problems
AVOID:
leading questions
multiple questions
SUMMARIZE:
Feedback to patient your
understanding of story
If you are lost
If you are uncertain
If done/transition
Getting started
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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
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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
• Allergies
• Hospitalizations
• Immunizations
• Surgeries
• Transfusions
• Significant injuries
• Gynecologic and
• Medications
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 therapies
Allergies
– describe reaction
Immunizations
Transfusions
Gyn 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
SUMMARY
Interviewing 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
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Location
Quality
Severity
Timing
Setting/context
Modifying factors
Associated symptoms
Summarize the visit
Ask for questions
Describe next step
involve patient, if decision needed
Thank you for listening