August 30, 2012

How To Take A Full Medical History

Medicine has been described as both a science and an art. The overall purpose of medical practice is to relieve suffering1. In order to achieve this purpose, it is important to make a diagnosis, to know how to approach treatment, and to design an appropriate scheme of management for each patient1.

It is therefore essential to understand each person as fully as possible, whatever their social class or ethnic and cultural background1. The first step toward understanding any patient is taking a medical history.

The art of obtaining a good medical history itself is a skill that is acquired through study and experience. It is necessary to be methodical and detailed, so as not to miss out facts that may seem little but in reality be the keystone to making the right diagnosis.

The following mnemonics may be quite helpful2:

1). When taking a history:
 Mnemonic: OPERATES
  • Onset of complaint
  • Progress of complaint
  • Exacerbating factors
  • Relieving factors
  • Associated symptoms
  • Timing
  • Episodes of being symptom-free
  • Relevant Systemic and general inquiry can be added here
2). Medications/allergies
Mnemonic: PILLS
  • Pills, is the patient taking any?
  • Injections/Insulin/Inhalers (as some patients forget to mention when asked about their medications)
  • ILLicit drug use
  • Sensitivities to anything, ie allergies
3). In every history, donʼt forget to ask about the ʻFAWRʼ non-specific symptoms that the patient may exhibit
Mnemonic: FAWR
  • Fever
  • Appetite
  • Weight loss (unintentional)
  • Reduced energy (i.e. fatigue/lethargy)
4). When assessing psychological state:
Mnemonic: SAD CASE
  • Suicidal ideations
  • Anxiety
  • Decreased mood/Delusions/Disordered thought
  • Difficulty Concentrating
  • Auditory or other hallucinations?
  • Difficulties Sleeping
  • Eating normally?

References:
  1. Swash M, Glynn M (eds). Hutchison's Clinical methods. The Approach to the Patient. Chap 1: Doctor and patient: General principles of history taking. 22nd ed.; 2007; Saunders Elsevier. 
  2. Revise4finals. Mnemonics. PasTest Ltd. 2008. Material available online at www.revise4finals.co.uk

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