Taking a Medical History

Question 1

What is the general structure for taking a medical history?

Answer 1

(PC) Presenting complaint

(HPC) History of presenting complaint

(PMH) Past medical history

(DH) Medication/allergies

(FH) Family history

(SH) Social history

(SE) Systems enquiry

Question 2

What is a useful mnemonic for pain in HPC?

Answer 2

Site
Onset
Character
Radiation
Associated symptoms
Time
Exacerbators/relievers
Severity

Question 3

What is a helpful mnemonc for PMH?

Answer 3

Jaundice
Anaemia or other haematological conditions
Myocardial infarction
Tuberculosis
Hypertension & heart disease
Rheumatic fever
Epilepsy
Asthma & COPD
Diabetes
Stroke

Question 4

What are they key points when taking a medical history?

Answer 4

\+ 2-way process
\+ Use your communication skills
\+ Order and structure
\+ Get as much detail as possible
\+ Be alert to 'red flags'
\+ COnsider patient's ideas, concerns, expectations (ICE)
\+ Summarise effectively
\+ Have a differential diagnosis/working diagnosis at the end