How to Take a Patient History (full guide) | KharmaMedic
Summary
TLDRIn 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
📚 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.
🔍 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.
💊 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.
👨👩👧👦 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.
Mindmap
Keywords
💡Clinical Practice
💡Medical History
💡Presenting Complaint
💡Systems Review
💡Past Medical History
💡Drug History
💡Family History
💡Social History
💡ICE
💡WIPER
💡Patient-Centered Interviewing
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
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