How To Take Medical History From Your Patients For Doctors and Healthcare Professionals

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Taking medical history from the patients is an essential skill for all doctors whatever their specialty, and medical history doesn't cover only the current symptom but it covers the whole person and all their medical issues, the short video below enumerate essential 25 questions to ask for your patients before examinations and through this topic we will summarize them:

1- Intro:
- Always smile
- Start by introducing yourself
- Confirm the identity of the patient including their name, age, gender and also they preferred name

2- Presenting Complaint:

Open Q about the presenting complaint

Re-cap and ask remaining questions about the presenting complaint from SOCRATES / ODPARA (Site - onset - character - radiation - association - what increase - what decrease - severity)

Acknowledge anything you see, for example offer painkiller if the patient is in pain but ask about pain grade/TTT before/allergy before administering painkiller

If the presenting complaint is secretion (vomiting - diarrhea - discharge - bleeding) ask about (related to anything in your mind - amount - color - blood clot if it is blood)

After exploring the presenting complaint, ask "Apart from your presenting complaint X, Is there anything else bothering you?" any new presenting complaint must be explored again in the same sequence as the 1st presenting complaint and explore if it the 1st time or not and explore previous complaints.

After exploring all the presenting complaints, ask "Apart from your presenting complaint X and X, what is your main concern? Are you worried about something specific? followed by "Why do you think in this way?" address his/her concern and "I’d like to ask few more questions to have better understanding for your condition and address your concerns"

Ask about DDs

FLAWS: Exclude "Red Flags" in all stations by asking about (Fever - Lethargy - Appetite - Weight loss - Sweating at night - Lumps and bumps) and also do fast systemic review by asking about different body systems.


3- Past medical history:

(Past history of the current presenting complaints "if yes, tell me more and explore" - Any medical conditions like DM, HTN, Asthma, Heart and cholesterol problems, Thyroid problems "explore any positive answer"- Any surgery, admission to hospital "explore any positive answer")


4- Personal history:

I will ask you some questions about your lifestyle: (Diet, Exercise, Smoking, Recreational drugs, Alcohol, Stress, Sexual) and again explore any positive answer


5- MAFTOSA:

Medications - Allergy - Family history - Travel History - Occupation - Social - Anything else

Occupation and social can be added to Presenting complain instead of here especially in chronic conditions "up to you"


6- Thanks + Ideas + Concerns + Expectations: Thank you very much for the information you have given to me, Do you have any idea in your mind about the cause of this X? What is your main concern? What do you expect us to do for you?


7- Examinations:

Is it ok to examine you? I need to check your observations and examine your ...


8- Provisional diagnosis: From what you have told me and from the examination, I am suspecting a condition called X? have you ever heard about it? It is a condition affecting "organ X" caused by Y and it is a "self-limiting or long-term" condition ... we need to do some investigations to reach a final diagnosis, if the diagnosis is confirmed we will do our best to stop the progression and to relieve your symptoms.

Then start your management plan by ordering investigations and scheduling another meeting or prescribing a medication or referring the patient ... etc.

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