How to Take a Patient History (full guide) | KharmaMedic

Summary

In this educational video, medical student Nasser from King's College London shares valuable insights on taking patient histories, emphasizing the importance of context, rapport, and structure. He outlines the essential components, including the presenting complaint, systems review, and patient's background. Nasser also highlights the significance of ICE (Ideas, Concerns, Expectations) in understanding the patient's perspective and offers practical tips for a comprehensive and empathetic approach to clinical practice.

Takeaways

• 😀 Building rapport with the patient is crucial for a smooth history taking process.
• 🏥 Understanding the context of the patient's visit is essential for guiding the direction of the questions.
• 📝 The structure of a patient history typically includes the presenting complaint, systems review, past medical history, drug history, family history, and social history.
• 🧊 ICE (Ideas, Concerns, Expectations) is a useful framework for identifying the patient's main concerns and expectations.
• 👋 Starting with an introduction, ensuring patient safety, and gaining consent is a fundamental step in history taking.
• 🗣️ Asking open-ended questions allows the patient to express their concerns fully before the doctor asks more specific questions.
• 🔍 The history of presenting complaint involves detailed exploration of the patient's current issue to understand its onset, duration, and progression.
• 📉 Systems review is a methodical way to check each body system for any issues that may have been overlooked.
• 💊 Drug history is vital to understand the patient's medication regimen, including any recent changes or non-adherence to the prescribed treatment.
• 👨‍👩‍👧‍👦 Family history can provide insights into genetic predispositions and the patient's risk for certain conditions.
• 🏘️ Social history, including lifestyle factors and living conditions, can impact a patient's health and is important for a comprehensive assessment.

Q & A

What is the primary focus of the video by Karma Medic?

The primary focus of the video is to discuss key points and techniques for effectively taking patient histories, which is a fundamental skill in clinical practice.

Who is the presenter of the video and what is their current educational status?

The presenter of the video is Nasser, a final year medical student at King's College London.

What is the significance of the acronym 'ICE' in the context of the video?

In the context of the video, 'ICE' stands for Ideas, Concerns, and Expectations, which is a method to help medical professionals understand the patient's perspective and emotions regarding their health issues.

How does the presenter suggest starting a patient history?

The presenter suggests starting a patient history by remembering the context of the interaction, being genuinely friendly and nice, and following a structured approach that includes the presenting complaint, systems review, past medical history, and other relevant sections.

What is the acronym 'WIPER' used for in the video?

The acronym 'WIPER' is used to remember the steps for patient safety and infection control at the beginning of a patient history, which stands for Washing hands, Introducing yourself, Patient details, Exposing the patient, and Repositioning.

What is the significance of the presenting complaint in a patient history?

The presenting complaint is significant as it represents the primary reason why the patient is seeking medical attention at that moment and serves as the starting point for further exploration during the history-taking process.

Why is the systems review an important part of the patient history according to the video?

The systems review is important because it ensures that the medical professional does not miss any relevant information about the patient's health and can remind the patient of issues they might have forgotten to mention.

What is the purpose of asking about a patient's past medical history?

Asking about a patient's past medical history is crucial to identify any existing conditions that may be related to the current complaint, understand the patient's health trajectory, and assess potential risks or complications.

How does the presenter suggest approaching the social history section of a patient history?

The presenter suggests approaching the social history section by asking about smoking, alcohol consumption, recreational drug use, occupation, living situation, and activities of daily living, while also being sensitive to the patient's feelings and circumstances.

What is the purpose of the final bonus tip provided by the presenter?

The final bonus tip is to help medical professionals who feel stuck during the history-taking process by prompting the patient to share any additional concerns or potential causes for their condition, which can provide new insights and ensure the patient feels heard.

Outlines

00:00

📚 Introduction to Patient History Taking

The video script introduces the importance of patient history taking in clinical practice, emphasizing its role as a fundamental skill for doctors. The speaker, Nasser, a final year medical student at King's College London, shares personal insights and key points learned during medical school. He clarifies that the content is for educational purposes and not professional medical advice. Nasser outlines the importance of context awareness and establishing rapport with patients, including the use of a friendly demeanor. The script also provides an overview of the structured approach to history taking, including the presenting complaint, systems review, and various patient history aspects such as past medical history, drug history, family history, and social history.

05:00

🔍 Deep Dive into Presenting Complaints and Systems Review

This paragraph delves into the specifics of the presenting complaint section of patient history, advocating the use of open-ended questions to allow patients to express their issues freely. It discusses the importance of exploring the details of the complaint using acronyms like SOCRATES for pain and other relevant medical history mnemonics. The paragraph also highlights the significance of the systems review, which involves asking about each body system to ensure nothing is overlooked, and emphasizes its utility in uncovering additional patient information that may have been forgotten or initially unmentioned.

10:02

💊 Comprehensive Coverage of Medical Histories and Drug Histories

The speaker discusses the critical nature of understanding a patient's past medical history, including chronic conditions that may not be immediately volunteered by the patient. It stresses the importance of inquiring about surgeries, hospital admissions, and emergency visits. The paragraph also covers drug history, including prescription and over-the-counter medications, and the necessity of identifying any recent changes in medication or potential allergies. A resource called Sketchy Medical is mentioned as a helpful tool for visual learners to remember drugs, their mechanisms, and side effects.

15:04

👨‍👩‍👧‍👦 Family and Social Histories: Their Role in Patient Assessment

The paragraph focuses on the family history's role in identifying genetic predispositions and conditions that may influence the patient's current health issues. It advises being sensitive when discussing family health, especially with older patients who may have experienced the loss of family members. The social history section inquires about lifestyle factors such as smoking, alcohol consumption, and recreational drug use, as well as living conditions and activities of daily living. The HEADSS assessment for adolescents and inquiries about mood and activities for the elderly are also mentioned, emphasizing the importance of a holistic approach to patient care.

👋 Conclusion and Call for Shared Experiences

In the concluding paragraph, the speaker invites viewers to share their own tips and tricks for taking patient histories, encouraging a collaborative learning environment. The video aims to be a useful resource, and the speaker expresses gratitude for viewers' engagement, promising more content in future videos. The call-to-action for feedback and shared knowledge underscores the video's educational intent and the speaker's commitment to continuous learning and improvement.

Keywords

💡Clinical Practice

Clinical practice refers to the direct patient care activities that health professionals engage in as part of their medical profession. It is central to the video's theme as the narrator discusses the importance of taking patient histories in clinical practice. The script mentions it as 'the core of clinical practice' and emphasizes the significance of this skill for a doctor's education and patient care.

💡Medical History

A medical history is a comprehensive account of a patient's health, including past illnesses, medications, and other relevant health information. In the video, the narrator highlights the importance of taking a medical history as a fundamental skill for doctors, outlining the process and various components such as the presenting complaint, systems review, and patient's background.

💡Presenting Complaint

The presenting complaint is the primary reason a patient seeks medical attention at a given time. It is a key concept in the video, as the narrator explains how to elicit detailed information about this from the patient using open-ended questions, which is crucial for diagnosis and treatment planning.

💡Systems Review

A systems review is a methodical inquiry into each body system to identify any symptoms or conditions that may not be immediately apparent. The narrator describes it as 'so so so useful' in the script, emphasizing its role in ensuring that no relevant health issue is overlooked during the patient history.

💡Past Medical History

Past medical history involves understanding a patient's previous health conditions, surgeries, and hospital admissions. The script underscores its importance for identifying potential complications or underlying conditions related to the current complaint.

💡Drug History

Drug history encompasses all medications a patient is currently taking, including prescription and over-the-counter drugs, as well as any recent changes to their medication regimen. The video script highlights the importance of this information for understanding potential side effects and medication adherence.

💡Family History

Family history is an account of illnesses and conditions within a patient's family, which can provide insights into genetic predispositions. The narrator mentions the importance of asking about family history to put the patient's current health issues into context, especially for conditions with a genetic component.

💡Social History

Social history includes information about a patient's lifestyle, such as smoking, alcohol consumption, and recreational drug use. The video script describes the importance of this information for understanding the patient's overall health and potential risk factors.

💡ICE

ICE stands for Ideas, Concerns, and Expectations, a framework used to understand the patient's perspective on their health issue. The narrator describes ICE as a useful tool for focusing the conversation and uncovering important information that might otherwise be missed.

💡WIPER

WIPER is an acronym used to remember the initial steps in taking a patient history: Washing hands, Introducing oneself, Patient details, Exposing the patient if necessary, and Repositioning. The script uses WIPER to illustrate the importance of patient safety and infection control during the initial stages of history taking.

💡Patient-Centered Interviewing

Patient-centered interviewing is an approach that focuses on the patient's experiences, concerns, and expectations. The video script advocates for this approach by emphasizing the importance of connecting with the patient, being genuine, and adapting the interview structure to the patient's needs.

Highlights

Emphasizing the importance of history taking as a fundamental clinical skill for doctors.

Sharing personal experiences and learnings from medical school regarding patient history.

The necessity of understanding the context when taking a patient's history.

The significance of establishing rapport with the patient at the beginning of the history taking process.

Structuring the history taking process with an outline that includes presenting complaint, systems review, and various histories.

Adapting the history taking structure to be more fluid based on the patient's responses.

Introducing the 'ICE' method (Ideas, Concerns, Expectations) to better understand the patient's perspective.

The importance of a proper introduction, patient safety, and infection control measures at the start of the history.

Confirming patient identity and obtaining consent before proceeding with the history.

Approaching the presenting complaint with an open-ended question to allow the patient to elaborate.

Exploring the history of the presenting complaint using detailed questioning.

Utilizing mnemonics like SOCRATES for pain and MOSQUE for gynecological history to guide questioning.

Summarizing the information gathered from the patient to ensure accuracy and completeness.

Conducting a systems review to check each body system for any additional symptoms.

Gathering a comprehensive past medical history to identify potential connections to the current complaint.

Inquiring about the patient's medication history, including allergies, to understand potential impacts on their health.

Discussing the importance of family history in understanding genetic predispositions to certain conditions.

Assessing the patient's social history, including habits like smoking and drinking, and their living situation.

Using the HEADS mnemonic for adolescents and assessing ADLs for elderly patients to understand their social and functional status.

Screening for mood and mental health as part of the social history.

Offering a final open-ended question to the patient to ensure no concerns are left unaddressed.

Transcripts

[Music]

what is up guys karma medic here and

welcome back to another dose taking a

history arguably the core of clinical

practice and the most important skill

that a doctor needs to learn in today's

video i want to talk about some of the

key points that i've learned throughout

my time in medical school which have

been really helpful for me when taking

patient histories in the hopes that

anyone watching who needs a little bit

more structure or information will find

them useful if you're new to the channel

then hi my name is nasser and i'm now a

final year medical student studying at

king's college london i think this video

requires a bit of a disclaimer i am not

a doctor i am a final year medical

student and all of the content of this

video is for information and education

purposes only this is not medical advice

this is not the perfect guide to taking

a history or anything like that this

video is a collection of things that

i've been taught in my medical school

and things that i've personally found

useful when on the hospital during

clinical placement now with that lovely

disclaimer out of the way let's get

right into it so before starting the

history there's generally two things

that i try and keep in mind first of all

i try to remember the context that i'm

in so if i'm talking to a patient in the

emergency department that's gonna be

very different to talking to someone in

general practice or in the cardiology

ward on top of that talking to someone

who's just been admitted to hospital on

day one might be very different to

talking to a patient who's now on day

five they might be a bit more relaxed a

bit more happy to talk to me as a

medical student as compared to when they

just walked into a e complaining of

something like pain this helps me stay a

bit focused that i can direct my

questions and thinking towards why the

patient is here to begin with the second

thing is that being overly nice smiley

happy genuine kind etc when beginning a

patient history i find goes such such a

long way even if the patient is quite

grumpy to begin with and doesn't really

want to talk to me as a medical student

i find that by the time i've introduced

myself exchanged a couple of friendly

smiles and asked them some questions

about them i've already made great

strides in connecting with the person in

front of me and the history just becomes

smooth sailing from there so moving on

to the actual history the general

outline of a history is as follows you

have the presenting complaint history of

presenting complaints systems review

past medical history drug history family

history social history etc now this is

subject to change based on the clinician

the situation but definitely for me as a

medical student i find it very helpful

to have this structure because i make

sure that i get through all the topics

that i want to and that i don't forget

any key information but patients are

very different and i think it's

important to be able to adapt and sort

of go forwards and backwards be a bit

more fluid with the structure if

necessary but i don't always follow the

structure patients can be very different

and letting them lead the conversation

and us being a bit more fluid with the

different sections sometimes makes for a

much better history now on top of this

structure something that i try not to

forget something that king's college

london as a medical school has forever

drilled into my brain is called ice so i

stands for ideas concerns and

expectations and i actually find it

really useful for honing in and finding

out exactly what the problem is that the

patient has come in with today if a

patient has five different things that

they want to discuss then asking them if

there's anything in particular that's

concerning them might help hone down and

focus the conversation asking about

ideas and expectations also allows the

patient to express their emotions and

feelings which is something that can be

easily forgotten if we're just going

through the structure trying to pick out

all the important medical information so

i do feel like it unlocks an extra level

to the history and sometimes gives that

really important information that you'd

otherwise miss i'll talk about eyes

further in the video as we go along but

for now let's start with approaching the

patient so every patient history starts

the exact same way starts with an

introduction patient safety and

infection control this is commonly

remembered with the acronym wiper which

stands for washing hands introducing

yourself patient details exposing the

patient if necessary and reposition so

washing your hands obviously good for

infection control but also to show the

patient that you're now clean if you

move on to examine them after or during

the history now introducing yourself of

course is very important we generally

give our name our grade and where we are

for example hi good afternoon my name is

nasr karma and i'm one of the final year

medical students here on the respiratory

ward this very quickly and adequately

explains who i am after that we move on

to patient safety so you want to double

check that the person who's in front of

you is the actual patient who you are

intending to talk to or take bloods from

or perform an examination on this is

done by confirming two pieces of

information commonly the patient's name

and date of birth so for example could i

start by confirming your name and age

please asking for age instead of the

date of birth helps you skip the mental

math in your head of trying to figure

out how old someone born in 1957 is age

gives you a lot of information to begin

with and also gives you a lot of context

for the presenting complaint of the

patient a 15 year old a 45 year old and

a 65 year old presenting with per

vaginal bleeding has a very different

set of differentials finally explain

what it is that you're here to do and

gain consent obviously this is very

important you need verbal confirmation

from the patient that they are happy to

go ahead and talk to you so what i'll

usually say after i've introduced myself

and confirmed the patient details is

something along the lines of i've been

asked by one of my seniors to have a

conversation with you about what's

brought you into the hospital and your

past medical history would that be okay

and only once they've agreed to have

this conversation with me i can move on

to asking them questions starting with

the presenting complaint so the first

part of the history is the presenting

complaint or in the us i believe this is

called the presenting illness so this is

when you're trying to understand from

the patient the exact reason why they

are in the emergency department general

practice or hospital right now for

example a patient might say that they

fell over or hurt their foot that they

feel their heart is beating very fast

they're having shortness of breath or

they've noticed a new rash on their back

this very specific singular thing is the

presenting complaint a really great way

of getting this information from the

patient is by asking them an open-ended

question and just letting them talk for

as long as they need to before we ask

another question we've been taught by

kings that this is like the golden rule

of taking a history you ask one

open-ended question and then let the

patient talk for as long as they need to

without interrupting so my go-to

question is something along the lines of

could you please tell me what's brought

you in today or can you please tell me

what's brought you into the hospital

after this question the patient usually

goes on to describe everything that's

going on that might be one thing or

three things but now i know what they

are and i can go into further detail

about them in the history of presenting

complaint so the history of presenting

complaint or the history of presenting

illness is about further exploring

whatever the presenting complaint was so

you take what the patient told you and

you just dig dig dig and explore explore

explore and find out everything that's

going on surrounding that thing so for

example when did this start is it old or

is it new how long does it last what

medication have you tried already etc

etc my classic go-to question over here

is could you please tell me more about

that now there's some really good

acronyms for some of the most common

presentations and types of histories for

example if someone is complaining of

pain one of the common things used to

explore that pain is an acronym called

socrates so socrates stands for sight

onset character radiation associated

symptoms timing exacerbation or

relieving factors and then scale or

severity so this is kind of an easy way

to remember all the different things

that you need to ask when it comes to

pain if it's a gynological history we

use the main outline of mosque which

stands for menstruation obstetrics sex

and contraception if it's an obstetric

history we use gmc if it's a pediatric

history we use bfgd there's all kinds of

acronyms for different kinds of

histories regardless of what the history

is i always try to ask adopt which is

d-o-p-t it stands for duration onset

progression and timing i always find it

really helpful and i think it helps put

the patient's presenting complaint into

a lot of perspective by the end of the

history of presenting complaint you

should have a really detailed idea

surrounding the events that brought the

patient into the hospital what happened

before during and after is especially

important for things like episodes of

collapse for episodes of self-harm by

now you've probably started thinking

about what direction you want to take

this history in and how you want to

narrow down to ask your more focused and

specific questions this is a good time

to ask those more specific questions

that will help you include or exclude

the most serious diagnoses for example

for someone with chest pain you want to

make sure that you exclude something

like a myocardial infarction or a

pulmonary embolism i generally find this

also a good time to cover ice i tend to

ask something along the lines of do you

have any idea what might have brought

this on or do you have any idea what

might have caused this most of the time

the patient will say i don't know which

is obviously completely fine and

reasonable but other times a patient

will say something like i bought a dog

around the time all this started

happening or there was a really

stressful event in my life or something

like that after you've gotten most of

the information from the history

presenting complaint this is a good time

to summarize back to the patient

everything that you've heard from them

this has two main benefits the first is

that the patient feels like they've

actually been listened to and that

you're taking their complaints seriously

the second is that if you've

misunderstood something from the patient

or they've forgotten to tell you

something in particular this is a good

time to fill in those blanks and now

we're ready to move on to the systems

review this is so so so useful it's

actually something that i never used to

do because i thought it would take up

way too much time especially in the

pressures of an oski exam but i found a

great way of doing it and i think it can

be very helpful it helps me make sure

that i don't miss anything and that i

get every single detail and it helps

remind the patient of something else

that they might have forgotten to tell

you so systems review is exactly what it

sounds like it's when you ask a couple

of questions for each of the systems of

the body just to kind of peek in and

check on each of the systems to make

sure that they're okay now as you become

more confident you can ask specific

questions that focus on the specific

body systems that you think are relevant

based off of the presenting complaint

and history of percentage complaint but

i'm definitely not at that point yet and

i like to ask questions from each of the

body systems to make sure i don't miss

anything i'll put a picture of all the

possible questions you could ask

somewhere up over here you'll never have

enough time to ask them all so you want

to pick and choose the most important

ones for the history that you're taking

so here's how i do a systems review i

say to the patient that i'm going to ask

a couple of questions back to back bear

with me it might seem like a lot but

it's just to make sure that i don't miss

anything and once they say okay i can

begin for example have you had any

headaches recently any changes to your

vision have you had a sore throat runny

nose or difficulty swallowing have you

had any chest pain have you felt like

your heart is beating very quickly any

shortness of breath or cough any nausea

or vomiting any tummy pain any changes

in your bowel habit or your water works

working normally any rashes or joint

pain and then finally and very

importantly the constitutional symptoms

so any fevers night sweats or

unexplained weight loss and that's it it

takes something like 30 seconds to 45

seconds and covers a ton of information

if i missed anything during my

investigation in the history presenting

complaint then it's most likely gonna

show up here now moving on to the past

medical history this is extremely

important sometimes the problem that the

patient is presenting with now can be a

complication of an existing condition or

an event in their past medical history

so getting every bit of information here

is key one thing that i found is that

some patients don't consider things like

asthma high blood pressure diabetes as

part of their past medical history

probably because it's something that's

very chronic that they've been living

with for a long time and so they don't

see it as a condition or illness that

they have so it's something that i

always screen for and make sure to ask

specifically you can usually get all the

relevant information from the patient by

asking them something along the lines of

do you have any long-term health

conditions or any illnesses that you see

your gp for another important thing to

ask is whether the patient has ever had

any surgery been admitted to the

hospital or had any visits to a e some

people find the mnemonic jam threads

helpful but personally i don't use it if

you're interested the acronym stands for

jaundice anemia myocardial infarction

tuberculosis hypertension rheumatic

fever epilepsy asthma and copd diabetes

and stroke drug history so this one

tends to be quite simple you simply ask

for all the medications that the patient

is currently taking whether that's

prescription drugs or over-the-counter

drugs sometimes it's also important to

ask whether any medications have

recently been stopped or any new

medications have been started even

though medicines and drugs are amazing

and help cure a whole wide range of

conditions almost all of them even the

ones that you might think are really

benign that a lot of people take will

also come with side effects for example

things like antihypertensives

antiglycemics statins these are

medicines that a lot of people take and

are considered to be fairly common but

they all have their side effects so

having a list of all this medication is

really important also something worth

asking is do you take your medications

regularly as prescribed there's no point

in us having it in our systems that the

patient is taking ex-wines at medication

if they don't actually take it when

they're at home one resource that has

helped me immensely in remembering

pretty much everything that i need to

know regarding medication is sketchy

medical sketchy medical is this visual

learning resource that helps you

remember drugs their mechanism of action

their side effects etc through these

beautifully weird drawn out pictures

personally whenever i'm asked about a

medication on a ward round or something

like that i will literally picture out

that image from sketchy medical and go

to the part of the drawing that helps me

answer the question it's a great

resource you should honestly check it

out if you don't know about it already

last thing in the drug history and

something you never ever ever ever want

to forget is to ask if the patient is

allergic to anything whether that's

medication or non-medication this has to

be written down in the notes somewhere

so family history is exactly what it

sounds like i tend to ask something like

do you have any illnesses or conditions

that run in the family something else

you could say is can you tell me about

the health of your family again over

here i feel like being specific about

things like asthma diabetes and

hypertension is sometimes needed i've

found that patients don't tend to bring

these up unless specifically asked a

patient's family history can put into

perspective their presenting complaint

especially if it's a condition that has

a strong genetic component a family

history of heart disease diabetes liver

or kidney disease etc now especially

with older patients it's likely that

their parents or siblings may have

already passed away and so it's

important to be sensitive when asking

these questions and trying to elicit

this information one important thing to

ask if a family member has died from a

specific disease is at what age they

passed away someone passing away from

cancer at the age of 40 or 50 is going

to be very different than someone in

their 90s i think over time you'll

develop your own way of sensitively

asking for this type of information but

generally just showing empathy and

compassion wherever you can goes a

really long way and finally social

history the all-important social history

common questions asked in this section

are if the patient smokes and if so how

much if the patient drinks and if so how

much and also if the patient uses any

recreational drugs now before that last

question it's important to signpost a

lot of people can get offended if you

ask them about the use of recreational

drugs something i like to say is a bit

of a strange question but it's something

that we ask all of our patients do you

use any recreational drugs also in the

social history if you've forgotten to

ask previously please don't forget to

ask about allergies other important

things to ask here are about the

patient's occupation and what their

living situation is like at home so for

example who do they live with at home

how many floors are there in the house

are there stairs etc if you're speaking

to a child or adolescent then the

acronym heads can be very useful this

stands for home education activity or

employment drugs and then sex social

life and suicide if you're talking to an

elderly patient something that's good to

ask is about their adls or activities of

daily life so are they able to go to the

shops and get groceries for themselves

are they able to cook and clean after

themselves etc and then lastly this is

also a good time to screen for a mood so

something you can ask is how things been

at home recently how would you describe

your mood something along those lines so

one final bonus tip this is something

that i used to use a lot especially when

i first started taking history if i ever

feel like i'm really stuck and i feel

like i haven't managed to find out

exactly what's going on i used to say

something along the lines of the

following okay mr smith you've given me

quite a lot to think about today is

there anything you think might have

caused this or anything that's

concerning you in particular this

usually helped solve all of my issues

and on top of that it helped cover ideas

and concerns from ice just generally if

you're feeling stuck honestly going

through ice is very helpful and that's

it please bear in mind that this video

is sort of an amalgamation of what i've

been taught at my medical school and

what i've learned things that i found

particularly helpful throughout the

years this is by no means the golden

rule book to taking a patient history

and i'm sure that there's better ways to

do all of the sections speaking of which

if you've got any tips or tricks or

something helpful that you'd like to

share please do leave them in a comment

down below i'll be reading through them

and incorporating them into my history

taking thanks so much for watching i

hope you find this video useful and i

will catch you in the next one

peace