Getting a more complete medical history?

R

rails

Forum Lieutenant
Premium Member
Messages
117
Reaction score
5
Points
18
I have been having some difficulty getting patients to provide me a full medical history as I go through SAMPLE. I've tried questions such as, "Do you have any medical conditions I should be aware of?", "What kind of medical history do you have?", etc. They will mention one or two things but not a more complete list.

I get the most information in response to "What have you been diagnosed with in the past?", but I often still need to ask them about specific diagnoses that they don't mention (e.g. diabetes).

Does anyone have any advice? I find that patients have been pretty open and seemingly comfortable with me, but they often seem to believe that certain conditions may not be relevant (?) and thus don't mention them until I ask by name. I just want to avoid not discovering something like CHF or Type II diabetes until after I write down their medications and recognize the drugs. :D
 
I always phrase my questions as though I'm having a conversation. The FIRST thing I do is get a list of medications and then I start to ask my questions around the medications. If they're taking lisinopril I say, "so I see you take some high blood pressure medicine. Has that been working well for you?"

And then the next line is, "and what else are you seeing the doctor for?"

Another good technique is to ask a series of questions about body parts. "Ever have any problems with your brain? Ever have a stroke or an aneurysm?"
"How about your heart? Ever have a heart attack? Ever have an irregular heartbeat?"
"And your lungs? You have trouble breathing? Do you have asthma? Do you have COPD or emphysema?"

I use that line of questioning for patients that are less than forthcoming. That usually gives me enough information that I can have a decent history when I present to the ER doc
 
rails said:
I have been having some difficulty getting patients to provide me a full medical history as I go through SAMPLE. I've tried questions such as, "Do you have any medical conditions I should be aware of?", "What kind of medical history do you have?", etc. They will mention one or two things but not a more complete list.
Click to expand...

I'd leave off the I should be aware of part. It implies there are medical problems you don't need to be aware of. Other than that, I tend to question people like DEMEdic.
 
DEmedic said:
I always phrase my questions as though I'm having a conversation. The FIRST thing I do is get a list of medications and then I start to ask my questions around the medications. If they're taking lisinopril I say, "so I see you take some high blood pressure medicine. Has that been working well for you?"

And then the next line is, "and what else are you seeing the doctor for?"

Another good technique is to ask a series of questions about body parts. "Ever have any problems with your brain? Ever have a stroke or an aneurysm?"
"How about your heart? Ever have a heart attack? Ever have an irregular heartbeat?"
"And your lungs? You have trouble breathing? Do you have asthma? Do you have COPD or emphysema?"

I use that line of questioning for patients that are less than forthcoming. That usually gives me enough information that I can have a decent history when I present to the ER doc
Click to expand...

I do the same thing. Start with the brain and work my way down all the various systems.
 
Ask direct questions like DE said. If you leave them open you won't get what you need.
 
Thanks, everyone!

I particularly like DEmedic's suggestion of asking questions about body parts as you go through the body systematically (e.g. heart, lungs, etc.).
 
I know that we're technically taught to use so called 'open ended' questions and the reasoning behind that is indeed sound, however, a lot of the time, it just doesn't give us the desired result. In that case, I've found that it is a lot of times easier to actually ask more directed and so called 'closed ended' questions.

Meds are a great way to figure out what problems you're working with. System by system is another great suggestion and one used a lot.

The question I use most is 'do you have any medical problems that you know about: heart problems, strokes, the like?' I don't list off too many things otherwise they start answering yes or no and assume that you're going to list off every single problem you can think of for them to answer, but it gives them the general idea. It'll still usually take some additional probing to get the full set of problems, but it's a good start.

Another note, be careful not to let the pt go off onto too many tangents, else you'll find yourself listening to stories of how they survived the flu of 1918 and how they had pneumonia in the 1970's!!
 
Start open and move towards closed for each section.

"Do you have any medical problems? So no diabetes [pause], high blood pressure, [pause], cancers, [pause] lung problems, [pause] heart problems?

Have you ever had surgery before? So you still have your gall bladder, appendix, tonsils, etc?"
 
JPINFV said:
Start open and move towards closed for each section.

"Do you have any medical problems? So no diabetes [pause], high blood pressure, [pause], cancers, [pause] lung problems, [pause] heart problems?

Have you ever had surgery before? So you still have your gall bladder, appendix, tonsils, etc?"
Click to expand...

You ever been hospitalized before?
 
I tend to just start naming off a bunch of things in the initial history. "Heart problems, lung problems, diabetes, high blood pressure,..." etc. I get more in-depth as needed.
 
My partner had to interrogate a patient for 30 minutes just to get a decent history for a repetitive transport. Why did she have to do this you may ask? Because the day before I had actually felt that the patient had something attached to their side under their clothing. I asked what it was and the patient swore up and down there was nothing there. I asked for medications and got one med out of the patient, started rattling off meds she SHOULD be on for the few conditions I managed to get out of her... nope, just the one med. This goes on for a bit and I give it a rest, I'm with a female partner for her next transport so I told her that the patient was not forthcoming with me about her history and she might open up to a female more. Ehhh, not exactly... as I said firstly, it took 30 minutes of non-stop questioning during the transport to get a semi-complete history (and it turns out the device I felt was a Baclofen pump, and that was not the one med she told me about).

Some patients are just either completely unwilling or unable to give you a history without extraordinary measures. Some are great though, occasionally you run into someone who has a complete med list printed out and laminated.
 
Last edited by a moderator:
JPINFV said:
I basically live in a hospital now... does that count?
Click to expand...


It's an important part of your history. Raises the risk of heart disease and stroke, and cancer too.

Maybe lowers the risk of skin cancer if you never have any fun outside.
 
Certainly put you at greater risk for hospital acquired infection. Make sure nobody sneezes on you. And no licking any used medical equipment.
 
There will always be patients that are not forthcoming about their medical history. I recently had a patient who was having shortness of breath, who admitted to some COPD… and that's it. When I pressed him on medications he said albuterol and that's it. He wouldn't tell me anything else. "Are you sure?" I kept asking. I knew there was more, the guy just looked sick. He said, "no not a thing."

However, when I arrived at the hospital and was able to speak with the ED doc about him, he said "oh yeah I'm very familiar with Mr blank. Did he tell you about his HIV status, fungal infections, cardiac history and liver failure?"

"No doc, he didn't."
 
JPINFV said:
Start open and move towards closed for each section.

"Do you have any medical problems? So no diabetes [pause], high blood pressure, [pause], cancers, [pause] lung problems, [pause] heart problems?

Have you ever had surgery before? So you still have your gall bladder, appendix, tonsils, etc?"
Click to expand...

This is exactly what I do.

"Ever been admitted to the hospital?"

"Do you take any medications every day? Do you take any medications sometimes?"
 
Remi said:
This is exactly what I do.

"Ever been admitted to the hospital?"

"Do you take any medications every day? Do you take any medications sometimes?"
Click to expand...

Thanks. That last part is great. I have noticed that on the medication list (either from their own list or from the collection of medication bottles they provide), that often some patients are very inconsistent on certain medications. Your question about "Do you take any medications sometimes?" would be helpful there.
 
We are taught in medical school to start open and go focused. A simple what brings you in today can help you narrow it down a lot and guide specific questions. This is our more focused history checklist. (Word Document)

This Graphic Might also be Useful
 

Attachments

  • History.jpg
    History.jpg
    20 KB · Views: 265
  • Checklist for history taking.pdf
    Checklist for history taking.pdf
    180.7 KB · Views: 2,402
samiam said:
We are taught in medical school to start open and go focused. A simple what brings you in today can help you narrow it down a lot and guide specific questions. This is our more focused history checklist. (Word Document)

This Graphic Might also be Useful
Click to expand...

The checklist is helpful -- thanks! Do you have a larger version of the graphic? It won't zoom in without blurring.
 
Try this, I think the site compressed it in png format
 

Attachments

  • History.jpg
    History.jpg
    97.6 KB · Views: 256
You must log in or register to reply here.
Back
Top