Medical history

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

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Overview

The medical history or anamnesis of a patient is information gained by a physician or other healthcare professional by asking specific questions, either of the patient or of other people who know the person and can give suitable information (in this case, it is sometimes called heteroanamnesis), with the aim of obtaining information useful in formulating a diagnosis and providing medical care to the patient. This kind of information is called the symptoms, in contrast with clinical signs, which are ascertained by direct examination. Most health encounters will result in some form of history being taken. Medical histories vary in their depth and focus. For example an ambulance paramedic would typically limit their history to important details such as name, history of presenting complaint, allergies etc. In contrast, a psychiatric history is frequently lengthy and in depth as many details about the patients life are relevant to formulating a management plan for a psychiatric illness. The information obtained in this way, together with clinical examination, enables the physician to form a diagnosis and treatment plan. If a diagnosis cannot be made then a provisional diagnosis may be formulated, and other possibilities (the differential diagnosis) may be added, by convention listed in order of likelihood. The treatment plan may then include further investigations to try and clarify the diagnosis.

Essential Parts of Medical history taking

History-taking may be comprehensive history taking (a fixed and extensive set of questions are asked, as practised only by medical students) or iterative hypothesis testing (questions are limited and adapted to rule in or out likely diagnoses based on information already obtained, as practised by busy clinicians). Computerised history-taking could be an integral part of clinical decision support systems. A physician typically asks questions to obtain the following information about the patient:

Identification and demographics

• The name, age, height, weight.

Presenting complaint (PC)

• This is the most important part to determine the reason patient seeks care. Important to consider using the patient’s terminology. This almost always provides you a “title” for the encounter.

History of presenting complaint (HOPC)

• This provide a thorough description of the chief complaint and current problem. The suggested format is as follow: P-Q-R-S-T.

• P: precipitating and palliative factors: It is essential to identify factors that make symptom worse and/or better; any previous self-treatment or prescribed treatment, and patient's response.
• Q: quality and quantity descriptors: Allow her/him to identify own rating of symptom (e.g., pain on a 1–10 scale) and descriptors (e.g., numbness, burning sensation, stabbing).
• R: region and radiation: Ask enough questions to identify the exact location of the symptom and any area of radiation
• S: severity and associated symptoms: Try to identify the symptom’s severity (e.g., how bad at its worst) and any associated symptoms (e.g., presence or absence of nausea and vomiting, caused dyspnea, associated with chest pain).
• T: timing and temporal descriptions: This helps to identify when complaint was first noticed; how it has changed/progressed since onset (e.g., remained the same or worsened/improved); whether onset was acute or chronic; whether it has been constant, intermittent, or recurrent.

• Another mnemonic used sometimes is 'SOCRATES' with questions Site, Onset, Character, Radiation, Association, Timing of complaint, Exacerbating, and Alleviating factor and Severity.

Direct question about the differential

• Direct question regarding differential diagnosis and the associated risk factors with these diagnosis.

Past medical history (PMH)

• Similar presenting complaints in past
• Past history of any other illnesses
• Hospitalization [duration and nature (e.g., elective or urgent)]
• Past history of any surgeries
• Stroke, Epilepsy, anesthesia problems
• Heart disease, blood pressure
• TB, Bronchitis, asthma
• Peptic ulcer, Jaundice
• Diabetes
• Rheumatic fever

Drug history

• Over the counter (OTC) drugs
• Prescription drugs
• Tablets/Injections
• Allergies
• Herbal remedies

• Habits: Smoking, alcohol use, therapeutic drugs, substance/drug abuse, sleep and exercise patterns [(e.g., tea and coffee consumption in the evening may aggravate frequency of urination at night (Differential diagnosis of nocturia should always kept in mind)].
• Sociocultural: Be polite and careful. These questions will help to identify occupational and recreational activities and experiences, living environment, financial status/support as related to patient's health care, needs, travel, lifestyle, etc.
• Family history: A carefully taken family history helps to identify potential sources of hereditary diseases. A genogram (if possible) is helpful; the minimum includes first degree relatives (parents, siblings, children), although 2–3 orders for each topics are helpful. Consider cardiovascular disorders, lung diseases (e.g., tuberculosis, asthma), skin lesions, allergies, food intolerance, history of oral and genital ulcerations etc.
• Review of systems: Start from vital signs (regardless of the complaints) and review a list of possible symptoms that the patient may have noted in each of the body systems.

• The "chief complaint (CC)" — the major health problem or concern, and its time course.
• History of present illless (HOPI) - details about the complaints enumerated in the CC.
• History of past illness (HPI)(including major illnesses, any previous surgery/operations, any current ongoing illness, eg diabetes)
• Review of systems(ROS) Systematic questioning about different organ systems
• Family diseases
• Childhood diseases
• Social history- including living arrangements, occupation, drug use (including tobacco, alcohol, other recreational drug use), recent foreign travel and exposure to environmental pathogens through recreational activities or pets.
• Regular medications (including those prescribed by doctors, and others obtained over the counter or alternative medicine)
• Allergies
• Sex life, obstetric/gynecological history and so on as appropriate.

Review of systems

Whatever system a specific condition may seem restricted to, it may be reasonable to review all the other systems in a comprehensive history. A review of system (ROS) should cover these 14 subheadings according to the legal billing policies in the US:

• Constitutional symptoms (e.g., fever, weight loss)
• Eyes
• Ears, nose, mouth, and throat
• Cardiovascular
• Respiratory
• Gastrointestinal
• Genitourinary
• Musculoskeletal
• Integumentary
• Neurological
• Psychiatric
• Endocrine
• Hematologic/lymphatic
• Allergic/immunologic

See also

• Genogram
• Historian (medical)
• Medical record
• Medicine
• Physical examination
• Psychoanalysis (Freud uses the term anamnesis to describe neurotics' recounting of their symptoms)

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