Comprehensive history taking
A comprehensive history taking is a way to perform a History-taking from a patient. The features of it is that the questioner have a complete set of questions to ask, in contrast to iterative hypothesis testing, where the questioner adapt his/her questions to the circumstances. Therefore, comprehensive history taking is mostly performed by Medicine students, who aren't yet as experienced that they can improvize. Afterwards, the Medicine student can report all the answers to a physician, who can put the right w:diagnosis.
Performance
[edit | edit source]This is an example of how a comprehensive history taking could be performed.
Presentation
[edit | edit source]- Greet the patient, present yourself and the purpose of the meeting.
- Listen Start with open-ended questions and let the patient tell freely.
- Specify with restricted questions.
- Why do you seek health care today? New trouble or worsening of an earlier one?
- w:Symtoms
- Localization. Where? Does it change position?
- Debut
- Duration
- Worsening factors. Body position? Exercise? Food intake?
- Alleviating factors. Is there anything that makes the symtoms better?
- Restriction of life. Worse sleep? Apetite?
Ongoing illnesses
[edit | edit source]E.g. w:diabetes, w:rheumatism, hypertension
Past medical history
[edit | edit source]Includes illnesses that are already treated.
- major illnesses,
- any previous surgery/operations
It's important to get to know:
- What illness?
- when?
- where it was treated
- how it was treated
Medication
[edit | edit source]What kind of medicines is the patient taking? It also includes:
- Medication taken regularily as well as when necessary
- Over-the-counter medications
- contraceptive pills
It's important to know:
- Form (pills, injections)
- Name
- Strength (mg/pill)
- Doses/day
Heredity
[edit | edit source]Has anybody in the family had similar problems?
Social
[edit | edit source]- Profession. Environment? Stress? Tasks? Unemployed?
- Family. Live alone or with husband/wife? Children? How many? Do they live nearby?
- Residence. House? Flat? Which floor? Is there an elevator?
- ADL Independent or home help? Get about with stick/walker.
- w:Exercise and w:nutrition
- w:Tobacco smoking. How many cigarettes/day? Smoked earlier?
- w:Alcoholic beverages. How many centilitres of beer, wine and spirits.
Gynecologic
[edit | edit source]This is of interest in fertile women or women after w:menopause.
- w:Menstruation-problems?
- Pregnancies?
- Deliveries?
- Menopause?
- Gynecologist-contacts?
Abuse
[edit | edit source]- Ongoing drugs?
- Debut?
- Treatment?
- Complications?
- Withdrawal-symptoms?
- Social contacts?
- Contact with addiction health care?
Allergies
[edit | edit source]To medications? Food? What is the reaction? Rashes? w:Dyspnea?
Organ-specific questions
[edit | edit source]In addition to general questions, the Medicine student could also have an arsenal of organ-specific questions, in order to put the right w:differential diagnosis.
w:Gastrointestinal problems
[edit | edit source]- How long time?
- Consistency of faeces?
- Number of defecations/day?
- Nocturnal problems?
- Blood content?
- Problems after meal?
- Pain?
- Weight loss?
Upper abdominal problem
[edit | edit source]- w:Heartburn?
- Changes with body position?
- w:Epigastric pain?
- Does food alleviate?
- Does w:antacids alleviate?
- Nausea? Vomiting? (blood)
- w:Dysphagia?
- Colour of faeces?
- Nocturnal problems?
- Weight loss?
Liver disease
[edit | edit source]- Contact with w:hepatitis-patient?
- Formerly operated? (w: Cholelithiasis, w:tumor)
- Alcohol abuse?
- Drug abuse?
- Abdominal pain?
- w:Itch?
- w:Fever?
- w:Diarrhea?
Chest pain
[edit | edit source]- How long time?
- Have the problems changed?
- Duration of an attack?
- What triggers an attack?
- How does the patient break an attack?
- Localization?
- Characteristics of the pain?
- Radiation?
Dyspnea
[edit | edit source]- How long time?
- Is it constant or coming and going?
- Smoking?
- Cough? Blood present?
- Worsening factors
- Alleviating factors
Joint problems
[edit | edit source]- How long time?
- Which joints?
- w:Morning stiffness?
- Has the patient had any disease the month before the visit?
- Is the pain worse in rest or in motion?
- Symtoms from other organs?
Weight loss/fatigue
[edit | edit source]- How long time?
- Was there a triggering cause?
- Worsening factors?
- Does sleep alleviate?
- Variations over the day?
- Is the appetite normal?
- How large weight loss?
- Colour and consistency of faeces?
- Amount and colour of urine?
Unconsciousness
[edit | edit source](A relative gives the medical history)
- When did the patient become unconscious?
- Was there a sudden or gradual debut?
- Urine/faeces-micturition?
- Cramps?
- What was the colour of the skin?
- Medications?
- Psychiatric symtoms?
- Suicidal thoughts?
- Abuse?
- w:Physical trauma?
- Vomiting?
Finally, Sum up what the patient has said to be sure you've got it right.
References
[edit | edit source]- Kompendium för Status och anamnes, Anders Albinsson (translated from Swedish)