Hospital Corpsman Sickcall Screener's Handbook
BUMEDINST 6550:9A
Naval Hospital Great Lakes
1999
Taking a Medical History
Basics: Allow the patient to talk. Do not interrupt. When patient is finished then ask open ended type questions. Always ask: Is there anything else?
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There are many methods and guides used for history taking and as time goes by you will develop your own style. Below are examples of a Medical History:
Classical Medical History
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Chief Complaint: chronological narrative of problem.
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onset
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quality
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severity
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timing (duration, frequency)
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what makes worse/better
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associated manifestations
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Past Medical History
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general state of health
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childhood illnesses
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immunizations
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adult illnesses
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psychiatric illnesses
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surgeries
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injuries
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hospitalizations
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ALLERGIES
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Current Medications
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Diet
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Sleep Pattern
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Habits
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smoking
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dipping
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ETOH intake
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Family History
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HTN
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TB
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HA
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Stroke
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heart disease
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diabetes
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mental illness
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Psychosocial History
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life style, home situation, significant others
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school
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job
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financial
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recreation
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Review of Systems
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General
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usual weight
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weight change
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weakness, fatigue, fever
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Skin
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rashes
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lumps
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itching
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dryness
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color changes
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hair and nails
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Head
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HA
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head injury
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Eyes
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vision
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corrective lens use; type
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last eye exam
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pain
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redness
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tearing
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double vision
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Ears
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hearing
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tinnitus
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vertigo
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pain, earache
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infection
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discharge
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Nose & Sinuses
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frequent colds, nasal stuffiness
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hay fever, atopy
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nosebleeds
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sinus trouble
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Mouth & Throat
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teeth and gums
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last dental exam
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sore tongue
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frequent sore throat
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hoarseness
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Neck
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lumps in neck
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pain
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Breasts
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lumps
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nipple discharge
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pain
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self-exam
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Respiratory
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cough
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sputum (color, quantity)
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hemoptysis
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wheezing
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asthma
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bronchitis
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pneumonia
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TB, last PPD
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pleurisy
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last CXR
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Cardiac
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heart trouble
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HTN
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rheumatic fever
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heart murmurs
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dyspnea/orthopnea
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edema
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chest pain/palpitations
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last EKG
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Gastrointestinal
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trouble swallowing
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heartburn
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appetite
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nausea
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vomiting
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vomiting blood
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indigestion
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frequency of BMs, last BM, change in habit
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rectal bleeding or tarry stools
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constipation
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diarrhea
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abdominal pain
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food intolerance
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excessive belching or farting
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hemorrhoids
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jaundice, liver or gall bladder trouble, hepatitis
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Urinary
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frequency of urination
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polyuria
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nocturia
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dysuria
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hematuria
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urgency, hesitancy, incontinence
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urinary infections and STDs
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stones (renal calculi)
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Genito-reproductive
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MALE
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discharge from or sores on penis
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STD hx and treatment, Last HIV test
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hernias
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testicular pain or masses
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frequency of intercourse, libido, difficulties
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FEMALE
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1st menarche, regularity, frequency
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flow duration, amount
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bleeding between periods or after intercourse
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last PAP, results
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number of pregnancies, deliveries, abortions (spontaneous & induced)
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STDs hx and treatments, Last HIV test
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Musculoskeletal
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joint pain/stiffness, arthritis, backache.
(describe location and swelling, redness, pain, weakness, ROM)
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past injuries, treatments
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Neurologic
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fainting, blackouts, seizures, paralysis, weakness, numbness, tingling, tremors, memory
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Psychiatric
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mood, affect
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nervousness, tension, depression
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past care
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Endocrine
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thyroid trouble
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heat or cold intolerance
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excessive sweating, thirst, hunger, urination
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diabetes
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Hematologic
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anemia
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ease of bruising, bleeding
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past transfusions and any reactions
ANOTHER FASTER WAY TO TAKE A MEDICAL HISTORY IS BY USING THE KEY WORD "SAMPLE PQRST"
S: Symptoms
A: Allergies
M: Medicine taken
P: Past history of similar events
L: Last meal
E: Events leading up to illness or injury
P: Provocation/Position - what brought symptoms on, where is pain located.
Q: Quality - sharp, dull, crushing etc...
R: Radiation - does pain travel
S: Severity/Symptoms Associated with - on scale of 1 to 10, what other symptoms occur
T: Timing/Triggers - occasional, constant, intermittent, only when I do this. (activities, food)
EXAMPLE:
S) 21 y/o male c/o sore throat. No known allergies. Taking no meds. Have approx (2) ST per year. Eating and drinking normally. Was fine until yesterday morning when woke up with ST. Denies fevers, chills, sweats, SOB, & HA.
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Bureau of Medicine and Surgery
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Operational Medicine
Health Care in Military Settings
CAPT Michael John Hughey, MC, USNR
NAVMED P-5139
January 1, 2001 |
United States Special Operations
Command
7701 Tampa Point Blvd.
MacDill AFB, Florida
33621-5323 |
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