Very quick medical history taking (in 2 minutes)
7 questions are required. Really!
When a patient is unwell in A&E, time is of the essence. So you need to be able to take an adequate medical history briefly. You may have to do this at the same time as a nurse is taking observations and starting oxygen etc.
So. Here goes. Very quick medical history taking (in 2 minutes).
These are the 7 questions we recommend. Start with:
1. Introduction – “You are Mr/Mrs X and Y years old. Is that correct?” (check their details and DoB before you engage)
2. PC – “What is the current problem .. (pause; listen after each pause) .. when did it start .. (pause) .. and how quickly did it start (suddenly, rapidly or gradually?)” Listen carefully. Write it down.
3. HPC – “Have you had it before .. (pause) .. what makes it better or worse .. (pause) .. and have you noticed anything else” Ditto.
4. PSH/PMH – “What major operations have you had? .. (pause) .. and have you ever had .. diabetes, jaundice, anaemia, tuberculosis, heart attacks, strokes, high blood pressure, epilepsy, rheumatic fever, or ulcers in your tummy?”
5. Drugs/Allergies – “Please show me a list of your current medication .. (pause) ..and if you have a serious allergy to any tablet, what is it?”
6. SH. “Have you ever smoked, or ever been a regular heavy drinker .. (pause) .. and what was your last job?”
7. FH. “How are your parents? .. OR .. Are your parents alive fit and well? .. OR .. What did you parents die of (depending on age of patient) .. (pause ) .. and are there any rare diseases in the family?”
Multi-tasking
Of course, this may not be enough and an examination and investigations are usually necessary. It is best not to cut corners and go for speed, unless the patient is very unwell.
But you may need to multi-task, and get on with treatment at the same time as assessment – e.g. if they are in pulmonary oedema or septic shock. Then you should, as you are taking this history:
- Obtain venous access
- Put oxygen on
- Sit up (or lie down)
- Call senior (+/- crash team if you need help now)
- Get someone to look up latest e-discharge summary and/or clinic letter.
Summary
We have described very quick medical history taking (in 2 minutes). If you are a student, you will not have enough experience to do this, and will need more time. It is better to use the slower methods below. But we have shown you it is possible.
