When taking a medical history from a client it is very important to phrase your questions correctly. Asking, "Does Fred drink a lot of water?" is leading the client, and possibly in the wrong direction. Just as when you are performing a physical examination, your job is to collect as much information as possible and asking questions in the same order every time will lead to a complete history. Show
You should always review the patient's chart prior to meeting with the client. If possible it is a good idea to read through at least the last year of visits. That can seem like a lot of information but there are many times when a DVM suggested a diagnostic test that has somehow been missed or a phone message the client never received. Our job is not to let anything slip by. Review the patient's problem list, vaccine history and last blood work performed and look at the blood results. By reviewing these you will know what to discuss with the owner. Review the signalment; age, species/breed, gender/altered. Know not just the patient's and client's names but how to pronounce them prior to entering the exam room. When entering the exam room be sure to introduce yourself to the client and the patient. If you already know the client, a sincere greeting and a few cordial words prior to taking the history will most likely put the client at ease which will make your job easier. The following questions may seem unnecessary to the client, especially if the pet is ill, but take a few moments to explain the importance to the client. You need to consider the reason the pet is being seen and collect all the information needed to immediately treat the patient, but at some point you will need to have all the questions answered. The questions that follow should be asked at any visit, well or sick; additional questions below are indicated only for sick visits. Keep in mind it is not possible for us to touch on every illness or injury a patient will present for in this article. It is a good idea when taking a history to use a checklist; this is a great way of making sure we do not forget anything. Taking a history from a patient is a skill necessary for examinations and afterwards as a practicing doctor, no matter which area you specialise in. It tests both your communication skills as well as your knowledge about what to ask. Specific questions vary depending on what type of history you are taking but if you follow the general framework below you should gain good marks in these stations. This is also a good way to present your history. In practice you may sometimes need to gather a collateral history from a relative, friend or carer. This may be with a child or an adult with impaired mental state. Procedure StepsStep 01Introduce yourself, identify your patient and gain consent to speak with them. Should you wish to take notes as you proceed, ask the patients permission to do so. Step 02 - Presenting Complaint (PC)This is what the patient tells you is wrong, for example: chest pain. Step 03 - History of Presenting Complaint (HPC)Gain as much information you can about the specific complaint. Sticking with chest pain as an example you should ask:
The SOCRATES acronym can be used for any type of pain history. Step 04 - Past Medical History (PMH)Gather information about a patients other medical problems (if any). Step 05 - Drug History (DH)Find out what medications the patient is taking, including dosage and how often they are taking them, for example: once-a-day, twice-a-day, etc. At this point it is a good idea to find out if the patient has any allergies. Step 06 - Family History (FH)Gather some information about the patients family history, e.g diabetes or cardiac history. Find out if there are any genetic conditions within the family, for example: polycystic kidney disease. Step 07 - Social History (SH)This is the opportunity to find out a bit more about the patient’s background. Remember to ask about smoking and alcohol. Depending on the PC it may also be pertinent to find out whether the patient drives, e.g. following an MI patient cannot drive for one month. You should also ask the patient if they use any illegal substances, for example: cannabis, cocaine, etc. Also find out who lives with the patient. You may find that they are the carer for an elderly parent or a child and your duty would be to ensure that they are not neglected should your patient be admitted/remain in hospital. Step 08 - Review of Systems (ROS)Gather a short amount of information regarding the other systems in the body that are not covered in your HPC. The above example involves the CVS so you would focus on the others. These are the main systems you should cover:
Please note these are the main areas, however some courses will also teach the addition of other systems such as ENT/ophthalmology. Step 09 - Summary of HistoryComplete your history by reviewing what the patient has told you. Repeat back the important points so that the patient can correct you if there are any misunderstandings or errors. You should also address what the patient thinks is wrong with them and what they are expecting/hoping for from the consultation. A useful acronym for this is ICE [I]deas, [C]oncerns and [E]xpectations. Step 10 - Patient Questions / FeedbackDuring or after taking their history, the patient may have questions that they want to ask you. It is very important that you don’t give them any false information. As such, unless you are absolutely sure of the answer it is best to say that you will ask your seniors about this or that you will go away and get them more information (e.g. leaflets) about what they are asking. These questions aren’t necessarily there to test your knowledge, just that you won’t try and 'blag it'. Step 11When you are happy that you have all of the information you require, and the patient has asked any questions that they may have, you must thank them for their time and say that one of the doctors looking after them will be coming to see them soon. This guide is designed for students and doctors. If you are applying for medical school and would like more information on the UCAT please check out our complete guide and our guide on how to practice for your exam. We've also prepared a UCAT Practice Test to help you prepare for the exam. What types of questions are recommended when first starting to collect information about a patient's history?Closed-ended questions are those that can be answered with a yes or a no and open-ended questions require a more detailed answer in the patient's own words. Open-ended questions are preferred because their use provides more extensive information than do closed-ended questions.
What questions should be asked of the patient?5 Critical Questions to Ask Every Patient. What Are Your Medical and Surgical Histories? ... . What Prescription and Non-Prescription Medications Do You Take? ... . What Allergies Do You Have? ... . What is Your Smoking, Alcohol, and Illicit Drug Use History? ... . Have You Served in the Armed Forces?. What questions should I ask about history of illness?History of Present Illness
o When did it start / how long has it been going on? o Is this a new problem / first time having this problem? o Intermittent or constant? o What makes it worse • Any other symptoms that you have?
Which type of question is best when gathering information from a patient?Open-ended questions, which allow patients to discuss their concerns freely, are widely considered an efficient method gathering medical information from patients during a medical interview.
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