Methods of Medical History Inquiry
1. General Information
General information includes: name, gender, age, marital status, ethnicity, occupation, place of origin, workplace, current address, etc.
Main Complaint
The main complaint is the most distressing symptom, sign, and duration that the patient experiences when seeking medical attention. For example, “Palpitations for 3 days, worsened with chest pain for 1 day.”
Points to Note:
1. Accurately capture the main complaint; the patient’s statements may be disorganized and lack clarity, and there is generally only one or two main symptoms.
2. Clearly inquire about the location, nature, severity, and duration of the symptoms described in the main complaint; avoid vague or ambiguous language.
3. Generally, do not use diagnostic names or test results as the main complaint (e.g., chronic gastritis cannot be used as the main complaint if the gastroscopy shows chronic gastritis).
4. The main complaint should be concise, generally less than 20 words.
“General information and main complaint have been provided, no need to inquire further.”
1. Present Illness History 6 points
Focus on the main complaint, inquiring about the occurrence, development, changes, and treatment process of the disease from the onset to the current visit. Specifically inquire about the following:
1. Causes and triggers of the disease: Ask the patient about the specific time of onset, mode of onset, any triggering factors, initial symptoms and their characteristics, and what treatment was done at the onset. List in points.
2. Course of the disease: Inquire about the changes in the patient’s condition from the onset to the current visit, understanding the evolution and development trend of the disease, generally in chronological order, including any prodromal symptoms before onset, symptoms that appeared at certain stages after onset, changes in nature and severity, when symptoms worsened or improved, when new symptoms appeared, and whether there are any patterns in the changes, such as diurnal variations, worsening symptoms in the afternoon, or changes after consuming greasy or cold foods, and how the condition alleviated, such as how long after taking medication or resting the symptoms improve, and accompanying symptoms. List in points.
3. Treatment history: Inquire about the diagnoses and treatments the patient has received since the onset of the disease, in chronological order. For example, what examinations were done, what were the results; what diagnoses were made; what treatments were administered, and what were the effects and reactions, etc. List in points.
4. Current symptoms: Inquire about the symptoms the patient feels at the time of the visit. For example: temperature, sleep, diet, bowel and bladder habits, etc. List in points.
2. Past Medical History 1 point
Inquire about the patient’s general health status, past illnesses (mainly asking about common diseases such as hypertension, diabetes, coronary heart disease, cerebrovascular diseases, etc., and infectious diseases such as tuberculosis, hepatitis), surgical history, blood transfusion history, trauma history, vaccination history, etc.
3. Personal Lifestyle History 1 point
Inquire about the patient’s personal life experiences, mental and emotional state, dietary habits, smoking, alcohol, or other preferences, as well as living habits, marriage, and childbirth.
(1) Life experiences: Ask about the patient’s place of birth, current and past living locations, etc.
(2) Mental and emotional state: Inquire about the patient’s usual mental, psychological, and emotional state, such as being cheerful, anxious, depressed, irritable, or fearful.
(3) Dietary preferences: Inquire about the patient’s usual dietary preferences, such as a preference for sour, sweet, or spicy foods.
(4) Living habits: Inquire about the patient’s usual living habits.
(5) Marital status: Inquire whether the patient is married or cohabiting, and if necessary, inquire about sexual activity. Pay attention to protecting the patient’s privacy.
(6) Menstrual and reproductive history: For women, inquire about the age of menarche or menopause, menstrual cycle, duration of menstruation, amount, color, and quality of discharge. For married women, also inquire about the number of pregnancies, births, and any history of miscarriage, premature birth, or difficult labor.
4. Family History 1 point
Inquire about the health and illness status of the patient’s parents, siblings, children, and others closely related to the patient, such as spouses or cohabiting partners, including asking about the causes of death of direct relatives.
5. Allergy History 1 point
Mainly inquire about allergies to any medications or foods.
2. Inquiry Methods for Critically Ill Patients
For emergency or critically ill patients, focus on briefly inquiring about the main symptoms and conducting key examinations to save time for rescue and treatment. After the condition stabilizes, detailed inquiries can be conducted; do not delay treatment or rescue due to mechanical insistence on complete records.
3. Inquiry Methods for Follow-up and Referral Patients
For follow-up patients, focus on inquiring about changes in their condition after medication. Some chronic patients may have already undergone diagnosis and treatment before the visit; if treated at another hospital, further inquire about the examinations performed, results, diagnoses, treatments, and efficacy.
4. Inquiry Methods for Special Patients
When patients have special circumstances, such as anxiety and depression, psychiatric patients, disabled patients, those with low educational levels or language barriers, critically ill patients, the elderly, or children, appropriate comfort, encouragement, inspiration, and guidance should be provided based on the patient’s specific situation during the inquiry. If necessary, ask accompanying personnel to assist in providing the medical history. Timely verification of any unclear or questionable content in the patient’s statements, such as the relationship between the condition and time, or certain symptoms and examination results, should be conducted to improve the authenticity of the medical history.
5. Points to Note
1. Suitable Environment: Doctor-patient communication requires a quiet and comfortable examination room environment, which is conducive to both the doctor’s diagnosis and treatment and allows the patient to fully describe their condition. For certain conditions that are not suitable for public discussion, inquiries should be conducted privately or through one-on-one physical examinations.
2. Kind Attitude: Doctors should strive to gain the patient’s trust, maintain a kind attitude, and avoid creating artificial barriers between themselves and the patient, paying attention to listening during conversations.
3. Simple Language: During the inquiry, the doctor’s language should be simple and easy to understand, avoiding the use of medical terms that the patient may not understand, such as Shaoyang disease, heat accumulation, etc. The doctor should not express surprise at the patient’s condition, as this may cause negative stimulation and increase the patient’s psychological burden.
4. Avoid Suggestion: When the patient’s description of their condition is unclear or incomplete, the doctor can provide appropriate guiding prompts, but should not suggest or induce the patient to describe their condition based on their own subjective intentions.
1. Begin the inquiry by actively creating a relaxed and harmonious environment to alleviate the patient’s anxiety. Pay attention to protecting the patient’s privacy, using appropriate verbal or non-verbal cues to express a willingness to alleviate the patient’s pain and meet their needs, as this will help establish a good doctor-patient relationship and facilitate the smooth collection of medical history.
2. Allow the patient to fully express and emphasize what they consider important situations and feelings; only when the patient’s statements stray too far from the condition should the topic be flexibly redirected based on the main clues of the statements. Only the patient’s personal experiences and the actual process of changes in their condition can provide an objective basis for diagnosis.
3. Trace the exact time of the onset of the first symptoms until the current evolution process. If several symptoms appear simultaneously, it is essential to determine their order of occurrence. The data collected in this way can accurately reflect the temporal development of the disease.
4. Use transitional language between the two inquiry items, explaining to the patient the new topic to be discussed and the reason for it, so that the patient will not be confused about why the topic is changing and why these situations are being inquired about.
5. Use different types of questions based on the specific situation. 1. General questions (or open-ended questions) are often used at the beginning of the inquiry to obtain a large amount of information in a particular area, allowing the patient to narrate their condition like telling a story. 2. Direct questions are used to collect specific details, such as “How old were you when you had your tonsillectomy?” “When did your abdominal pain start?” The information obtained is more targeted. Another type of direct question requires the patient to answer “yes” or “no,” or respond to provided options, such as “Have you ever had severe headaches?” “Is your pain sharp or dull?” To systematically and effectively obtain accurate information, the inquirer should follow the principle of moving from general questions to direct questions.
6. Incorrect questioning may lead to erroneous information or omissions of relevant data. The following types of questions should be avoided: 1. Leading or suggestive questions, which imply the expected answer in their wording, making it easy for the patient to default or agree with the doctor’s suggestion, such as “Your chest pain radiates to your left arm, right?” “Your condition improved a lot after taking this medication, right?” etc. 2. Accusatory questions, which often cause the patient to become defensive, such as “Why do you eat such unhealthy food?” If the doctor indeed requires the patient to answer why, they should first explain the reason for asking the question; otherwise, it may be perceived as an accusation by the patient. 3. Consecutive questions, which involve asking a series of questions in succession, may confuse the patient about which questions they need to answer, such as “How does it feel after eating? Is it different from before eating? Is it sharp pain or dull pain?”
7. When questioning, pay attention to systematic and purposeful inquiry. Disorganized and repetitive questioning can reduce the patient’s confidence and expectations in the doctor. Sometimes, to verify information, the same question may need to be asked multiple times, but it should be explained, such as “You have told me that there is blood in your stool, which is very important information; please tell me more about your stool situation.” Sometimes, using techniques such as counter-questions and explanations can avoid unnecessary repetitive questioning.
8. At the end of each part of the medical history inquiry, summarize briefly to achieve the following purposes: 1) to stimulate the doctor’s memory and organize thoughts to avoid forgetting to ask questions; 2) to let the patient know how the doctor understands their medical history; 3) to provide an opportunity to verify the patient’s described condition. Summarizing the present illness history is often particularly important. A brief summary of the family history is sufficient, especially for negative or uncomplicated positive family histories. When summarizing the system review, it is best to summarize only positive findings.
9. Avoid medical terminology. Sometimes, the inquirer should provide appropriate explanations for difficult terms before using them, such as “Have you ever had hematuria, in other words, has your urine ever turned red?”
10. To collect the most accurate medical history possible, doctors may need to verify the information provided by the patient. For example, if the patient says, “I am allergic to penicillin,” the doctor should ask, “How do you know you are allergic?” or ask, “Was it a positive skin test for penicillin, or what reaction did you have when you took penicillin?” Information that often needs verification includes the amount of blood in vomit, changes in weight, the amount of stool and urine, the use of important medications such as glucocorticoids, anti-tuberculosis drugs, and psychiatric medications, as well as alcohol and smoking history, and allergy history.
11. Appropriately using some evaluative, praising, and encouraging language can promote cooperation between the patient and the doctor, encouraging the patient to actively provide information, such as “I can understand” “That must be very difficult for you” or “You have quit smoking? That takes willpower.” However, for patients with mental disorders, do not casually use praise or encouraging language.
12. Inquire about the patient’s economic situation, showing concern for whether the patient has economic and emotional support from family and work. Doctors can increase the patient’s trust by providing appropriate explanations based on different situations. Sometimes, it is necessary to encourage the patient to seek economic and emotional support and introduce some individuals or groups that can help the patient.
13. Doctors should understand the patient’s expectations, clarify the exact purpose and requirements of the patient’s visit. Doctors should assess what the patient is most interested in, what they want to know, and the amount of understandable information they can provide each time, thus providing appropriate information or guidance.
14. When patients ask questions that the doctor is unclear about or does not understand, the doctor should not casually respond, pretend to understand, or provide random explanations, nor should they simply answer “I don’t know.” If the doctor knows part of the answer or related information, they can explain and provide what they know for the patient’s reference. For questions that are not understood, the doctor can respond that they will look it up or consult others before answering, or suggest the patient consult someone else, or recommend where they can resolve the issue.
15. At the end of the inquiry, thank the patient for their cooperation, inform them of the importance of doctor-patient collaboration, explain the next steps required from the patient, what will be done next, the next appointment time, or follow-up plan, etc.
Through theoretical learning combined with practical training, one can better master the methods and techniques of inquiry. In actual work, one should be alert to specific situations and flexibly grasp them, continuously summarize experiences and learn from lessons. If necessary, one can ask oneself: Is the patient particularly uncomfortable at this time? Is the patient unable to express themselves? Is there a language barrier? Is the patient overwhelmed by the disease? Efforts should be made to discover the reasons affecting the inquiry and resolve them to continuously improve the level of inquiry.
By Zhonggong and Medical Examination Teaching Materials