And with 7 questions. Really!? Yes.
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.
So. Here goes. Very quick medical history taking (in 2 minutes). Clock on. Go ..
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 any major illnesses, including diabetes, jaundice, anaemia, tuberculosis, heart attacks, strokes, treatment for 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. “Who do you live with .. are you married .. and how many children do have you had?”
“Have you ever smoked, or ever been a regular heavy drinker .. (pause) .. and what was your last job?”
Note. Ok ok, so that’s two questions!
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:
Summary
We have described how to take a full medical history in 2 minutes, with 7 questions. 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.
[“Oh yes. When you get good, you can do this in ONE minute.” “Show off” “Yes!” MyHSN Ed]
