M10.02.02 Components of the Health History

A comprehensive health history is a crucial component of patient assessment, providing the foundation for accurate diagnosis and effective treatment planning. This section outlines the essential components of the health history, guiding medical students through the process of gathering detailed and relevant patient information.

Components of the Health History

1. Chief Complaint (CC)
   • Definition: The primary reason for the patient’s visit, expressed in their own words.
   • Importance: Focuses the clinical assessment and prioritizes the patient’s immediate concerns.
2. History of Present Illness (HPI)
   • Chronological Account: Details the onset, duration, and progression of the current condition.
   • Symptom Analysis: Involves a thorough examination of the characteristics, location, severity, and timing of symptoms.
   • Associated Symptoms: Identifies other related symptoms that may help in differential diagnosis.
3. Past Medical History (PMH)
   • Medical Conditions: Lists previous and current medical conditions and significant illnesses.
   • Surgical History: Records past surgeries, including dates and outcomes.
   • Medications: Includes all prescription, over-the-counter, and herbal medications.
   • Allergies: Documents any known drug, food, or environmental allergies and reactions.
4. Family History (FH)
   • Genetic Disorders: Identifies hereditary conditions and genetic predispositions.
   • Family Illnesses: Includes the health status of immediate family members and relevant medical conditions.
5. Social History (SH)
   • Lifestyle Factors: Assesses diet, exercise, tobacco use, alcohol consumption, and substance abuse.
   • Occupational History: Examines the patient’s occupation, work environment, and potential health hazards.
   • Living Situation: Includes information about the patient’s home life, support systems, and socio-economic factors.
6. Review of Systems (ROS)
   • Systematic Inquiry: Involves a comprehensive review of each body system to identify any additional symptoms or concerns.
   • Symptom Checklist: A series of questions covering various organ systems, from head to toe.

Tables

Table 1: Sample Chief Complaint Documentation

Key Points to Remember

• Chief Complaint: Always document in the patient’s own words to capture their primary concern accurately.
• History of Present Illness: Use a systematic approach to detail the symptom’s characteristics, ensuring nothing is overlooked.
• Past Medical History: Be thorough in documenting all medical conditions, surgeries, medications, and allergies to provide a complete picture.
• Family History: Identify any genetic predispositions that could impact the patient’s health.
• Social History: Consider lifestyle and socio-economic factors that may influence health and treatment adherence.
• Review of Systems: Conduct a comprehensive inquiry to ensure all potential health issues are identified and addressed.

Bibliography

1. Bates, B., & Dains, J. E. (2018). Bates’ Guide to Physical Examination and History Taking. Wolters Kluwer.
2. Swartz, M. H. (2019). Textbook of Physical Diagnosis: History and Examination. Elsevier.
3. Bickley, L. S., & Szilagyi, P. G. (2020). Bates’ Pocket Guide to Physical Examination and History Taking. Wolters Kluwer.
4. Jarvis, C. (2020). Physical Examination and Health Assessment. Elsevier.