Medical History - Process

Process

A practitioner typically asks questions to obtain the following information about the patient:

• Identification and demographics: name, age, height, weight.
• The "chief complaint (CC)" - the major health problem or concern, and its time course (e.g. chest pain for past 4 hours).
• History of the present illness (HPI) - details about the complaints, enumerated in the CC. (Also often called 'History of presenting complaint' or HPC.)
• Past Medical History (PMH) (including major illnesses, any previous surgery/operations (sometimes distinguished as "Past Surgical History" or PSH), any current ongoing illness, e.g. diabetes).
• Review of systems (ROS) Systematic questioning about different organ systems
• Family diseases - especially those relevant to the patient's chief complaint.
• Childhood diseases - this is very important in pediatrics.
• Social history (medicine) - including living arrangements, occupation, marital status, number of children, drug use (including tobacco, alcohol, other recreational drug use), recent foreign travel, and exposure to environmental pathogens through recreational activities or pets.
• Regular and acute medications (including those prescribed by doctors, and others obtained over-the-counter or alternative medicine)
• Allergies - to medications, food, latex, and other environmental factors
• Sexual history, obstetric/gynecological history, and so on, as appropriate.
• Conclusion & closure

History-taking may be comprehensive history taking (a fixed and extensive set of questions are asked, as practiced only by health care students such as medical students, physician assistant students, or nurse practitioner students) or iterative hypothesis testing (questions are limited and adapted to rule in or out likely diagnoses based on information already obtained, as practiced by busy clinicians). Computerized history-taking could be an integral part of clinical decision support systems.