138:
hospital?) followed by the history of present illness (to characterize the nature of the symptom(s) or concern(s)), the past medical history, the past surgical history, the family history, the social history, their medications, their allergies, and a review of systems (where a comprehensive inquiry of symptoms potentially affecting the rest of the body is briefly performed to ensure nothing serious has been missed). After all of the important history questions have been asked, a focused physical exam (meaning one that only involves what is relevant to the chief concern) is usually done. Based on the information obtained from the H&P, lab and imaging tests are ordered and medical or surgical treatment is administered as necessary.
365:. Some familiarity with the doctor generally makes it easier for patients to talk about intimate issues such as sexual subjects, but for some patients, a very high degree of familiarity may make the patient reluctant to reveal such intimate issues. When visiting a health provider about sexual issues, having both partners of a couple present is often necessary, and is typically a good thing, but may also prevent the disclosure of certain subjects, and, according to one report, increases the stress level.
147:
394:
One disadvantage of many computerized medical history systems is that they cannot detect non-verbal communication, which may be useful for elucidating anxieties and treatment plans. Another disadvantage is that people may feel less comfortable communicating with a computer as opposed to a human. In a
299:
a specific condition may seem restricted to, all the other systems are usually reviewed in a comprehensive history. The review of systems often includes all the main systems in the body that may provide an opportunity to mention symptoms or concerns that the individual may have failed to mention in
137:
the H&P). The history requires that a clinician be skilled in asking appropriate and relevant questions that can provide them with some insight as to what the patient may be experiencing. The standardized format for the history starts with the chief concern (why is the patient in the clinic or
360:
may be inhibited by a reluctance of the patient to disclose intimate or uncomfortable information. Even if such an issue is on the patient's mind, they often do not start talking about such an issue without the physician initiating the subject by a specific question about sexual or
406:. In 2021, a substudy of a large prospective cohort trial showed that a majority (70%) of patients with acute chest pain could, with computerized history taking, provide sufficient data for risk stratification with a well-established risk score (
342:. In such cases, it may be necessary to record such information that may be gained from other people who know the patient. In medical terms, this is known as a heteroanamnesis, or collateral history, in contrast to a self-reporting anamnesis.
662:
Pappas, Yannis; Wei, Igor; Car, Josip; Majeed, Azeem; Sheikh, Aziz (2011). "Computer-assisted versus oral-and-written family history taking for identifying people with elevated risk of type 2 diabetes mellitus". In Car, Josip (ed.).
387:. For example, patients may be more likely to report that they have engaged in unhealthy lifestyle behaviors. Another advantage of using computerized systems is that they allow easy and high-fidelity portability to a patient's
395:
sexual history-taking setting in
Australia using a computer-assisted self-interview, 51% of people were very comfortable with it, 35% were comfortable with it, and 14% were either uncomfortable or very uncomfortable with it.
92:, which are ascertained by direct examination on the part of medical personnel. Most health encounters will result in some form of history being taken. Medical histories vary in their depth and focus. For example, an
704:"Use of Self-Reported Computerized Medical History Taking for Acute Chest Pain in the Emergency Department - the Clinical Expert Operating System Chest Pain Danderyd Study (CLEOS-CPDS): Prospective Cohort Study"
313:
Genitourinary system (frequency in urination, pain with micturition (dysuria), urine color, any urethral discharge, altered bladder control like urgency in urination or incontinence, menstruation and sexual
846:
326:
Musculoskeletal system (any bone or joint pain accompanied by joint swelling or tenderness, aggravating and relieving factors for the pain and any positive family history for joint disease).
281:
A follow-up procedure is initiated at the onset of the illness to record details of future progress and results after treatment or discharge. This is known as a catamnesis in medical terms.
266:(a fixed and extensive set of questions are asked, as practiced only by health care students such as medical students, physician assistant students, or nurse practitioner students) or
133:
The method by which doctors gather information about a patient's past and present medical condition in order to make informed clinical decisions is called the history and physical (
304:
Cardiovascular system (chest pain, dyspnea, ankle swelling, palpitations) are the most important symptoms and you can ask for a brief description for each of the positive symptoms.
310:
Gastrointestinal system (change in weight, flatulence and heartburn, dysphagia, odynophagia, hematemesis, melena, hematochezia, abdominal pain, vomiting, bowel habit).
839:
755:"A prospective cohort study of self-reported computerised medical history taking for acute chest pain: protocol of the CLEOS-Chest Pain Danderyd Study (CLEOS-CPDS)"
320:
Cranial nerves symptoms (Vision (amaurosis), diplopia, facial numbness, deafness, oropharyngeal dysphagia, limb motor or sensory symptoms and loss of coordination).
383:
One advantage of using computerized systems as an auxiliary or even primary source of medically related information is that patients may be less susceptible to
338:
Factors that inhibit taking a proper medical history include a physical inability of the patient to communicate with the physician, such as unconsciousness and
564:"Computer-Assisted versus Oral-and-Written History Taking for the Prevention and Management of Cardiovascular Disease: a Systematic Review of the Literature"
832:
1373:
402:
comparing computer-assisted versus traditional oral-and-written family history taking to identifying patients with an elevated risk of developing
130:) may be added, listed in order of likelihood by convention. The treatment plan may then include further investigations to clarify the diagnosis.
317:
Nervous system (Headache, loss of consciousness, dizziness and vertigo, speech and related functions like reading and writing skills and memory).
270:(questions are limited and adapted to rule in or out likely diagnoses based on information already obtained, as practiced by busy clinicians).
307:
Respiratory system (cough, haemoptysis, epistaxis, wheezing, pain localized to the chest that might increase with inspiration or expiration).
1292:
802:
1310:
1233:
99:
would typically limit their history to important details, such as name, history of presenting complaint, allergies, etc. In contrast, a
1221:
1132:
1305:
275:
103:
is frequently lengthy and in depth, as many details about the patient's life are relevant to formulating a management plan for a
1254:
1114:
76:. It involves the patient, and eventually people close to them, so to collect reliable/objective information for managing the
880:
220:ā including living arrangements, occupation, marital status, number of children, drug use (including tobacco, alcohol, other
172:
1358:
615:"A randomised controlled trial comparing computer-assisted with face-to-face sexual history taking in a clinical setting"
1363:
346:
380:
systems have been available since the 1960s. However, their use remains variable across healthcare delivery systems.
1368:
1101:
207:
84:. The medically relevant complaints reported by the patient or others familiar with the patient are referred to as
1228:
1216:
917:
912:
388:
217:
201:
38:
1208:
403:
399:
384:
110:
The information obtained in this way, together with the physical examination, enables the physician and other
1300:
1083:
753:
Brandberg, H; Kahan, T; Spaak, J; Sundberg, K; Koch, S; Adeli, A; Sundberg, CJ; Zakim, D (21 January 2020).
464:
1337:
1272:
398:
The evidence for or against computer-assisted history taking systems is sparse. As of 2011, there were no
339:
224:), recent foreign travel, and exposure to environmental pathogens through recreational activities or pets.
127:
1144:
993:
357:
221:
323:
Endocrine system (weight loss, polydipsia, polyuria, increased appetite (polyphagia) and irritability).
1188:
1127:
978:
960:
907:
855:
434:
329:
Skin (any skin rash, recent change in cosmetics and the use of sunscreen creams when exposed to sun).
232:
182:
111:
169:(CC)" ā the major health problem or concern, and its time course (e.g. chest pain for past 4 hours).
1324:
1109:
1054:
922:
362:
100:
31:
1282:
1264:
1157:
1091:
890:
154:
A practitioner typically asks questions to obtain the following information about the patient:
1332:
1036:
885:
786:
735:
684:
644:
595:
541:
514:
290:
192:
185:(PMH) (including major illnesses, any previous surgery/operations (sometimes distinguished as
81:
77:
1178:
1026:
1011:
776:
766:
725:
715:
676:
668:
634:
626:
585:
575:
504:
493:"'The Cringe Report': Why patients don't dare ask questions, and what we can do about that"
1183:
1044:
875:
353:
244:
166:
89:
824:
126:
cannot be made, a provisional diagnosis may be formulated, and other possibilities (the
1162:
1049:
1021:
935:
781:
754:
730:
703:
639:
614:
439:
424:
300:
the history. Health care professionals may structure the review of systems as follows:
816:
1352:
927:
252:
1119:
1061:
983:
702:
Brandberg, H; Sundberg, CJ; Spaak, J; Koch, S; Zakim, D; Kahan, T (27 April 2021).
672:
196:
159:
532:
Mayne, JG; Weksel, W; Sholtz, PN (1968). "Toward automating the medical history".
345:
Medical history taking may also be impaired by various factors impeding a proper
1249:
1198:
1003:
771:
613:
Tideman, R L; Chen, M Y; Pitts, M K; Ginige, S; Slaney, M; Fairley, C K (2006).
231:(including those prescribed by doctors, and others obtained over-the-counter or
228:
17:
1152:
1071:
1066:
1016:
900:
407:
211:
175:(HPI) ā details about the complaints, enumerated in the CC (also often called
104:
580:
563:
509:
492:
988:
945:
630:
248:
123:
115:
96:
93:
73:
69:
790:
739:
688:
648:
599:
590:
518:
545:
1277:
429:
419:
271:
680:
349:, such as transitions to physicians that are unfamiliar to the patient.
895:
238:
146:
119:
85:
65:
940:
296:
1193:
720:
145:
970:
562:
Pappas, Y; VÅ”eteÄkovĆ”, J; Poduval, S; Tseng, PC; Car, J (2017).
828:
241:ā to medications, food, latex, and other environmental factors
204:ā especially those relevant to the patient's chief complaint.
497:
Journal of Family
Planning and Reproductive Health Care
391:. Also an advantage is that it saves money and paper.
189:
or PSH), any current ongoing illness, e.g. diabetes).
446:
to describe neurotics' recounting of their symptoms)
1323:
1291:
1263:
1242:
1207:
1171:
1143:
1100:
1082:
1035:
1002:
968:
959:
866:
486:
484:
482:
840:
195:(ROS) Systematic questioning about different
8:
274:history-taking could be an integral part of
965:
847:
833:
825:
780:
770:
729:
719:
638:
589:
579:
508:
27:Patient information gained by a physician
557:
555:
665:Cochrane Database of Systematic Reviews
456:
134:
7:
708:Journal of Medical Internet Research
352:History taking of issues related to
1234:Upper limb neurological examination
255:history, and so on, as appropriate.
25:
276:clinical decision support systems
1374:History of science by discipline
374:Computer-assisted history taking
369:Computer-assisted history taking
1255:Ballard Maturational Assessment
1115:Peripheral vascular examination
619:Sexually Transmitted Infections
177:history of presenting complaint
881:History of the present illness
673:10.1002/14651858.CD008489.pub2
467:. American Medical Association
173:History of the present illness
1:
1222:Miniāmental state examination
1133:Ankleābrachial pressure index
268:iterative hypothesis testing
264:comprehensive history taking
210:ā this is very important in
162:: name, age, height, weight.
68:is a set of information the
772:10.1136/bmjopen-2019-031871
378:computerized history taking
347:doctor-patient relationship
1390:
465:"Patient Responsibilities"
288:
36:
29:
1229:Cranial nerve examination
817:Resources in your library
400:randomized control trials
389:electronic medical record
218:Social history (medicine)
39:Medical History (journal)
581:10.14712/18059694.2018.1
510:10.1136/jfprhc.2011.0060
404:type 2 diabetes mellitus
385:social desirability bias
258:Conclusion & closure
80:and proposing efficient
30:Not to be confused with
1301:Athletic heart syndrome
631:10.1136/sti.2006.020776
534:Mayo Clinic Proceedings
340:communication disorders
1338:Differential diagnosis
1273:Well-woman examination
262:History-taking may be
151:
128:differential diagnoses
60:, "open", and Ī¼Ī½Ī®ĻĪ¹Ļ,
667:. pp. CD008489.
491:Quilliam, S. (2011).
442:(Freud uses the term
358:reproductive medicine
222:recreational drug use
187:past surgical history
149:
72:collect over medical
37:For the journal, see
1359:Practice of medicine
1306:Sudden cardiac death
1189:Shoulder examination
1128:Abdominojugular test
961:Physical examination
908:Past medical history
435:Physical examination
233:alternative medicine
183:Past medical history
112:health professionals
1364:Medical terminology
1325:Assessment and plan
1110:Cardiac examination
1055:Swinging light test
923:Psychiatric history
856:Medical examination
363:reproductive health
158:Identification and
101:psychiatric history
88:, in contrast with
32:History of medicine
1283:Breast examination
1158:Rectal examination
1092:Respiratory sounds
891:Nursing assessment
334:Inhibiting factors
227:Regular and acute
208:Childhood diseases
152:
82:medical treatments
56:(from Greek: į¼Ī½Ī¬,
1369:Athletic training
1346:
1345:
1333:Medical diagnosis
1319:
1318:
1194:Elbow examination
803:Library resources
291:Review of systems
285:Review of systems
193:Review of systems
78:medical diagnosis
64:, "memory") of a
16:(Redirected from
1381:
1179:Knee examination
1027:Respiratory rate
966:
849:
842:
835:
826:
795:
794:
784:
774:
750:
744:
743:
733:
723:
699:
693:
692:
659:
653:
652:
642:
610:
604:
603:
593:
583:
559:
550:
549:
529:
523:
522:
512:
488:
477:
476:
474:
472:
461:
136:
21:
1389:
1388:
1384:
1383:
1382:
1380:
1379:
1378:
1349:
1348:
1347:
1342:
1315:
1287:
1259:
1238:
1203:
1184:Hip examination
1172:Musculoskeletal
1167:
1139:
1096:
1078:
1045:Eye examination
1031:
998:
955:
876:Chief complaint
868:Medical history
862:
853:
823:
822:
821:
811:
810:
808:Medical history
806:
799:
798:
752:
751:
747:
701:
700:
696:
661:
660:
656:
612:
611:
607:
561:
560:
553:
531:
530:
526:
490:
489:
480:
470:
468:
463:
462:
458:
453:
416:
371:
336:
293:
287:
202:Family diseases
167:chief complaint
144:
46:medical history
42:
35:
28:
23:
22:
18:Patient history
15:
12:
11:
5:
1387:
1385:
1377:
1376:
1371:
1366:
1361:
1351:
1350:
1344:
1343:
1341:
1340:
1335:
1329:
1327:
1321:
1320:
1317:
1316:
1314:
1313:
1308:
1303:
1297:
1295:
1289:
1288:
1286:
1285:
1280:
1275:
1269:
1267:
1261:
1260:
1258:
1257:
1252:
1246:
1244:
1240:
1239:
1237:
1236:
1231:
1226:
1225:
1224:
1213:
1211:
1205:
1204:
1202:
1201:
1196:
1191:
1186:
1181:
1175:
1173:
1169:
1168:
1166:
1165:
1160:
1155:
1149:
1147:
1141:
1140:
1138:
1137:
1136:
1135:
1130:
1122:
1117:
1112:
1106:
1104:
1102:Cardiovascular
1098:
1097:
1095:
1094:
1088:
1086:
1080:
1079:
1077:
1076:
1075:
1074:
1069:
1059:
1058:
1057:
1052:
1050:Ophthalmoscopy
1041:
1039:
1033:
1032:
1030:
1029:
1024:
1022:Blood pressure
1019:
1014:
1008:
1006:
1000:
999:
997:
996:
991:
986:
981:
975:
973:
963:
957:
956:
954:
953:
952:
951:
948:
943:
938:
930:
928:Progress notes
925:
920:
918:Social history
915:
913:Family history
910:
905:
904:
903:
893:
888:
886:Systems review
883:
878:
872:
870:
864:
863:
860:history taking
854:
852:
851:
844:
837:
829:
820:
819:
813:
812:
801:
800:
797:
796:
765:(1): e031871.
745:
694:
654:
605:
551:
524:
478:
455:
454:
452:
449:
448:
447:
440:Psychoanalysis
437:
432:
427:
425:Medical record
422:
415:
412:
370:
367:
335:
332:
331:
330:
327:
324:
321:
318:
315:
311:
308:
305:
289:Main article:
286:
283:
260:
259:
256:
242:
236:
225:
215:
205:
199:
190:
180:
170:
163:
143:
140:
90:clinical signs
26:
24:
14:
13:
10:
9:
6:
4:
3:
2:
1386:
1375:
1372:
1370:
1367:
1365:
1362:
1360:
1357:
1356:
1354:
1339:
1336:
1334:
1331:
1330:
1328:
1326:
1322:
1312:
1309:
1307:
1304:
1302:
1299:
1298:
1296:
1294:
1290:
1284:
1281:
1279:
1276:
1274:
1271:
1270:
1268:
1266:
1265:Gynecological
1262:
1256:
1253:
1251:
1248:
1247:
1245:
1241:
1235:
1232:
1230:
1227:
1223:
1220:
1219:
1218:
1217:Mental status
1215:
1214:
1212:
1210:
1206:
1200:
1197:
1195:
1192:
1190:
1187:
1185:
1182:
1180:
1177:
1176:
1174:
1170:
1164:
1161:
1159:
1156:
1154:
1151:
1150:
1148:
1146:
1142:
1134:
1131:
1129:
1126:
1125:
1123:
1121:
1118:
1116:
1113:
1111:
1108:
1107:
1105:
1103:
1099:
1093:
1090:
1089:
1087:
1085:
1081:
1073:
1070:
1068:
1065:
1064:
1063:
1060:
1056:
1053:
1051:
1048:
1047:
1046:
1043:
1042:
1040:
1038:
1034:
1028:
1025:
1023:
1020:
1018:
1015:
1013:
1010:
1009:
1007:
1005:
1001:
995:
992:
990:
987:
985:
982:
980:
977:
976:
974:
972:
967:
964:
962:
958:
949:
947:
944:
942:
939:
937:
934:
933:
931:
929:
926:
924:
921:
919:
916:
914:
911:
909:
906:
902:
899:
898:
897:
894:
892:
889:
887:
884:
882:
879:
877:
874:
873:
871:
869:
865:
861:
857:
850:
845:
843:
838:
836:
831:
830:
827:
818:
815:
814:
809:
804:
792:
788:
783:
778:
773:
768:
764:
760:
756:
749:
746:
741:
737:
732:
727:
722:
721:10.2196/25493
717:
714:(4): e25493.
713:
709:
705:
698:
695:
690:
686:
682:
678:
674:
670:
666:
658:
655:
650:
646:
641:
636:
632:
628:
624:
620:
616:
609:
606:
601:
597:
592:
591:10044/1/69815
587:
582:
577:
574:(3): 97ā107.
573:
569:
565:
558:
556:
552:
547:
543:
539:
535:
528:
525:
520:
516:
511:
506:
502:
498:
494:
487:
485:
483:
479:
466:
460:
457:
450:
445:
441:
438:
436:
433:
431:
428:
426:
423:
421:
418:
417:
413:
411:
409:
405:
401:
396:
392:
390:
386:
381:
379:
375:
368:
366:
364:
359:
355:
350:
348:
343:
341:
333:
328:
325:
322:
319:
316:
312:
309:
306:
303:
302:
301:
298:
292:
284:
282:
279:
277:
273:
269:
265:
257:
254:
253:gynecological
250:
246:
243:
240:
237:
234:
230:
226:
223:
219:
216:
213:
209:
206:
203:
200:
198:
197:organ systems
194:
191:
188:
184:
181:
178:
174:
171:
168:
164:
161:
157:
156:
155:
148:
141:
139:
131:
129:
125:
121:
117:
113:
108:
106:
102:
98:
95:
91:
87:
83:
79:
75:
71:
67:
63:
59:
55:
51:
47:
40:
33:
19:
1209:Neurological
1163:Bowel sounds
1120:Heart sounds
984:Auscultation
867:
859:
807:
762:
758:
748:
711:
707:
697:
681:10547/296945
664:
657:
622:
618:
608:
571:
567:
537:
533:
527:
503:(2): 110ā2.
500:
496:
469:. Retrieved
459:
443:
397:
393:
382:
377:
373:
372:
351:
344:
337:
294:
280:
272:Computerized
267:
263:
261:
186:
176:
160:demographics
153:
132:
109:
61:
57:
53:
50:case history
49:
45:
43:
1250:Apgar score
1199:GALS screen
1084:Respiratory
1012:Temperature
1004:Vital signs
901:Medications
625:(1): 52ā6.
568:Acta Medica
540:(1): 1ā25.
408:HEART score
229:medications
122:plan. If a
105:psychiatric
1353:Categories
1153:Liver span
1017:Heart rate
994:Percussion
979:Inspection
932:Mnemonics
471:24 October
451:References
314:activity).
212:pediatrics
114:to form a
74:interviews
70:physicians
1145:Abdominal
989:Palpation
896:Allergies
444:anamnesis
295:Whatever
249:obstetric
247:history,
239:Allergies
124:diagnosis
120:treatment
116:diagnosis
107:illness.
97:paramedic
94:ambulance
54:anamnesis
1278:Pap test
1243:Neonatal
969:General/
950:COASTMAP
791:31969363
759:BMJ Open
740:33904821
689:22161431
649:17098771
600:29439755
519:21454267
430:Medicine
420:Genogram
414:See also
179:or HPC).
86:symptoms
1062:Hearing
782:7044839
731:8114166
640:2598599
546:5635452
150:Example
142:Process
66:patient
1293:Sports
1124:Other
941:OPQRST
936:SAMPLE
805:about
789:
779:
738:
728:
687:
647:
637:
598:
544:
517:
354:sexual
297:system
245:Sexual
135:a.k.a.
62:mnesis
1311:RED-S
1072:Rinne
1067:Weber
1037:HEENT
165:The "
52:, or
971:IPPA
946:SOAP
858:and
787:PMID
736:PMID
685:PMID
645:PMID
596:PMID
542:PMID
515:PMID
473:2020
118:and
44:The
777:PMC
767:doi
726:PMC
716:doi
677:hdl
669:doi
635:PMC
627:doi
586:hdl
576:doi
505:doi
410:).
376:or
356:or
58:anĆ”
1355::
785:.
775:.
763:10
761:.
757:.
734:.
724:.
712:23
710:.
706:.
683:.
675:.
643:.
633:.
623:83
621:.
617:.
594:.
584:.
572:60
570:.
566:.
554:^
538:43
536:.
513:.
501:37
499:.
495:.
481:^
278:.
48:,
848:e
841:t
834:v
793:.
769::
742:.
718::
691:.
679::
671::
651:.
629::
602:.
588::
578::
548:.
521:.
507::
475:.
251:/
235:)
214:.
41:.
34:.
20:)
Text is available under the Creative Commons Attribution-ShareAlike License. Additional terms may apply.
