When you fill out forms at your doctor’s office, do you wonder why it matters whether or not your grandmother had high blood pressure or diabetes? Your doctor also asks you questions like this. Why is it important? Your
medical history includes both your personal health history and your family health history. Your personal health history has details about any health problems you’ve ever had. A family health history has details about health problems your blood relatives have had during their lifetimes. This information gives your doctor all kinds of important clues about what’s going on with
your health, because many diseases run in families. The history also tells your doctor what health issues you may be at risk for in the future. If your doctor learns, for example, that both of your parents have heart disease, they may focus on your heart health when you’re much younger than
other patients who don’t have a family history of heart disease. If it’s possible, every adult should know their family health history. You may or may not already know some information about conditions that affected different family members. Even if you think you do, double-check
what you know. Find out even more about as many blood relatives as you can, and remember to include half-sisters and brothers. You should not include people who are not blood relatives, such as: Make sure to write down what you learn, in case you forget details over time. You’ll also be able to add to the information you already have. Make sure to share the information with your siblings, children, or grandchildren, as they get older. To get started, call your relatives, or ask them in person about your family health history. Let your relatives know you’re not being nosy, but just
want to gather details that could keep you and other family members healthy. You can offer to share what you learn, so that everyone can benefit from your research.Who to Include
Gather Your Family Health History
You’ll want to ask about common chronic [ongoing] health conditions. Find out how old each person was when they learned about their condition. You may want to start by asking about these common family health problems: You’ll need to know
the health history of relatives who have died, too. If you have access to death certificates or medical records, you can find out the cause of death and how old they were, but living relatives may know the details. If you were adopted, you may not know anything about your birth parents’ health history. If that’s the case, a big chunk of your medical history is a question mark. You may wonder if you’re at risk for heart
disease, cancer, or other diseases that run in families.If You’re Adopted
Rules vary by state, but most adopted people are able to access details about their birth parents’ family medical history once they become adults. Such information may be found through a state’s child welfare agency or the department that assists with adoptions.
How Your History Keeps You Healthy
Once you find out your medical history, you can make powerful choices for yourself. If you learn, for example, that heart disease runs in your family, you may decide to make lifestyle changes that could lower your risk, such as quitting smoking, losing weight, or getting more exercise.
Your doctor may also use the information to give you screening tests, which might catch a disease, such as cancer, early. There are lots of ways your medical history can put you and your doctor in better control of your health.
Free medical revision on history taking skills for medical student exams, finals, OSCEs and MRCP PACES
Introduction [WIIPP]
- Wash your hands
- Introduce yourself: give your name and your job [e.g. Dr. Louise Gooch, ward doctor]
- Identity: confirm you’re speaking to the correct patient [name and date of birth]
- Permission: confirm the reason for seeing the patient [“I’m going to ask you some questions about your cough, is that OK?”]
- Positioning: patient sitting in chair approximately a metre away from you. Ensure you are sitting at the same level as them and ideally not behind a desk.
Presenting Complaint
- Ask the patient to describe their problem using open questions [e.g. “What’s brought you into hospital today?”]
- The presenting complaint should be expressed in the patient’s own words [e.g. “I have a tightness in my chest.”]
- Do not interrupt the patient’s first few sentences if possible
- Try to elicit the patient’s ideas, concerns and expectations [ICE]
- e.g. “I’m worried I might have cancer.” or “I think I need some antibiotics.”
History of Presenting Complaint
- Ask the patient further questions about the presenting complaint
- A useful mnemonic for pain is “SOCRATES“ [Click here for further mnemonics]
- Site
- Onset
- Character
- Radiation
- Alleviating factors
- Timing
- Exacerbating factors
- Severity [1-10]
Past Medical History
- Ask the patient about all previous medical problems.
- They may know these medical problems very well or they may forget some. Top ensure none are missed ask about these important conditions specifically [mnemonic: “MJTHREADS Ca”]
- Myocardiac infarction
- Jaundice
- Tuberculosis
- Hypertension
- Rheumatic fever
- Epilepsy
- Asthma
- Diabetes
- Stroke
- Cancer [and treatment if so]
- If the patient is unsure of their medical problems, ask them further clarifying questions, for example “What do you usually visit your doctor for?”. Remember you can add to past medical history if any of the medication later mentioned don’t match the medical problems listed.
- Risk factors
- As part of medical history ask about specific risk factors related to their presenting complaint.
- For example, if the patient presents with what maybe a myocardial infarction, you should ask about associated risk factors
such as:
- Smoking, cholesterol, diabetes, hypertension, family history of ischemic heart disease.
- Clarification of past medical history
- Some medical conditions require clarification of the severity. For example:
- COPD
- Ask about when the patient was diagnosed, their current and previous treatments, whether they have ever required non invasive ventilation [“a tight-fitting face mask”], whether they have been to intensive care
- Myocardial infarction
- Ask about angina, previous heart attacks, any previous angiograms [“a wire put into your heart from your leg or from your arm”], previous stenting
- Diabetes
- Duration of diagnosis, current management including insulin and usual control of diabetes i.e. well- or poorly-controlled
Drug History
- All
medications that they take for each medication ask them to specify:
- Dose, frequency, route and compliance [i.e whether they regularly take these medication].
- If they take medication weekly ask what day of the week they take it.
- If they take a medication with a variable dosing [e.g. Warfarin] ask what their current dosing regimen is
- Recreational drugs
- Intravenous drug use [current or previous]
- Over the counter [OTC] medications
Allergies
- Does the patient have any allergies?
- If allergic to medications, clarify the type of medication and the exact reaction to that medication.
- Specifically ask about whether there’s been a history of anaphylaxis e.g. “throat swelling, trouble breathing or puffy face”
Family History
- Ask the patient about any family diseases relevant to the presenting complaints [e.g. if the patient has presented with chest pain, ask about family history of heart attacks].
- Enquire about the patient’s parents and sibling and, if they were deceased below 65, the cause of death
- If relevant and a pattern has emerged from previous history sketch a short family tree
Social History
- Alcohol intake
- Work out the number of units per week
- Tobacco use
- Quantify the number of pack years [number of packs of 20 cigarettes smoked per day multiplied by the number of years smoking]
- Employment history
- Particularly relevant with exposure to certain pathogens e.g. asbestos, where you need to ask whether they have ever been exposed to any dusts
- Home situation
- House or bungalow
- Any carers
- Activities of daily living [ability to wash, dress and cook]
- Mobility, and immobility aids
- Social/family support
- Do they think they’re managing?
- Travel history
- Further social history maybe required depending on the type of presenting complaint for example:
- Respiratory presenting complaint
- Ask about pets, dust exposure, asbestos, exposure to the farms, exposure to birds or if there are any hobbies
- Infectious to disease related
- Ask for a full travel history including all occasions exposure to water, exposure to foreign food, tuberculosis risk factors, HIV risk factors, recent immunisations
- Respiratory presenting complaint
Systems Review
- Run through a full list of symptoms from major systems:
- Cardiovascular: chest pain, palpitations, peripheral oedema, paroxysmal nocturnal dyspnoea [PND], orthopnoea
- Respiratory: Cough, shortness of breath [and exercise tolerance], haemoptysis, sputum production, wheeze
- Gastrointestinal: Abdominal pain, dysphagia, heartburn, vomiting, haematemesis, diarrohea, constipation, rectal bleeding
- Genitourinary: Dysuria, discharge, lower urinary tract symptoms
- Neurological: Numbness, weakness, tingling, blackouts, visual change
- Psychiatric: Depression, anxiety
- General review: Weight loss, appetite change, lumps or bumps [nodes], rashes, joint pain
Summary
- Provide a short summary of the history including:
- Name and age of the patient, presenting complaint, relevant medical history
- Give a differential diagnosis
- Explain a brief investigation and management plan
Click here for how to take history of chest pain
Perfect revision for medical student exams, finals, OSCEs and MRCP PACES