Medical history

In this podcast you will hear short dialogues detailing how to ask a patient about their medical history.

 

1. Personal details

Listen to the Health Professional ask about occupation and marital status. A spouse refers to a person’s husband or wife. To say that someone passed away, means that they died.

HP: What do you do for a living? P: Pardon?

HP: Do you work?

P: No, I am unemployed.

HP: Do you have a partner?

P: My spouse passed away. I live by myself.

 

2. Presenting Complaint

Listen to the Health Professional ask about the pain.

HP: Where does it hurt?

P: It’s my head. I have a terrible headache.

HP: Can you describe the pain?

P: It’s a throbbing pain.

HP: Does it go anywhere else?

P: It starts in my neck and the back of my head. It moves to the front of my head and stays behind my eyes.

HP: Does anything bring them on?

P: I don’t know, I usually get them at the end of the day. I don’t know what causes them. They can happen anytime.

HP: How long does the pain last?

P: They last all night and into the next day. They take at least 24 hours to disappear.

HP: How often does it happen?

P: I get them a few times a month.

HP: What relieves the pain?

P: I take a lot of over the counter medicine medicine, but nothing seems to work except time and sleep.

HP: Is your pain mild, moderate, or severe?

P: It ranges from moderate to severe usually. Now, my headache is severe.

 

3. Drug history

Listen to the health professional ask the patient about drugs, medications, doses, frequency of administration, compliance, allergies, and reactions.

HP: Are you taking any medications?

P: Yes, I take blood pressure pills.

HP: Do you use any over the counter medications or homeopathic medications? P: Yes, I take Aleve, aspirin, and some vitamins and pills from the natural store. HP: How many times a day?

P: I can show you. I take this 3 times a day, and these every morning with breakfast.

HP: Do you always remember to take the medication?

P: Sometimes, I forget, but I just double up when I remember.

HP: Do you ever experience side affects?

P: Yes, sometimes.

HP: What symptoms do you get after taking it?

P: I notice that I have rapid heartbeat with this pill. And I have trouble sleeping sometimes with these.

HP: Do you know if you are allergic to any drugs?

 

4. Family history

When taking a family history, the health professional will note the age, health, and cause of death of parents, siblings, spouse and children. Let’s listen to the health professional talk about family history.

HP: Are your parents alive and well? P: My mother is dead.

HP: How old was she when she died? P: 59

HP: What was the cause of death?

P: She had lung cancer.

HP: Does anyone else in your family have a serious illness?

 

5.Social personal history

When taking a social personal history, a health professional may inquire about the following things: occupation, housing, personal habits, recreation, drugs, alcohol, smoking, problems at work, financial problems, who shares house, ages. Let’s listen to a health professional ask the patient a few questions.

HP: Who shares a home with you? P: I live with my partner.

HP: What is your occupation?

P: I work at a bank.

HP: Do you have any problems at work?

P: My hours have been cut.

HP: Do you have any financial problems?

P: My partner’s son moved back in with us because he lost his job, so that is an added expense.

HP: What about exercise?

P: I try to get to the gym on weekends. HP: Do you smoke?

P: I gave up smoking a few years back. HP: Do you use drugs or alcohol?

P: No drugs. Wine occasionally.