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medical history female doctor
The art of History Taking...



...or is it a science ? They say medicine is both an art and a science. Hell forget it - I like to keep it logical and simple so that it works for me when I need it. We can't really have mnemonics for everything on the USMLE clinical skills assessment, but we sure can have protocols...

Step 1: SP tells you his/her chief complaints,

Step 2 : O.D.P + Details ..yeah that's right ! Ask about the Onset, Duration and Progress for each of the above complaints, followed by complete details about the complaint - for example, LIQOR AAA for pain; severity, pattern, chills/rigors for fever, quality, sputum, hemoptysis for cough etc.

Step 3 : Spefic Data-Collection for the case - If you have a specific Data-Collection mnemonic for the case - NOW IS THE TIME - for e.g. FACE SLIPS for Depression / Fatigue case.

Step 4 : History of all other symptoms that are possible for the system that is involved, which were not covered in Step 3 . Keep this handy - like cough, dyspnea, chest pain, wheezing, etc. are all symptoms possible in a respiratory case.

Step 5 : History of possible complications - if any

Now move on to 'PAMHUGS FOSS SODA'

Again this is guideline for those who are not confident about their history taking styles. But I do stress the importance of memorizing D/Ds and Data-Collection for each symptom complex - that makes asking the right questions during history taking get easy.

This approach rocks especially for those times when we suffer an idiopathic mental black out in front of the SP !! ;-)


To see the above approach in action - Look up the explanation for Heel Pain case on this blog: Click here




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COMMENTS ON ""

 

Anonymous Anonymous said ... (4:54 PM) : 

U r amazingly helpful & great idea

 

Anonymous prettydoc said ... (11:34 PM) : 

Hi there. This website you created is really great and very helpful. Thanks.
I just have some questions. I was wondering if your Step 3 -Step 5 would be equivalent to the review of systems and past medical history. I am more familiar with these terms.
Thanks again for this wodnerful site.

 

Blogger Digitaldoc, MD said ... (3:30 AM) : 

yes..it is. But splitting them into steps and assigning a logical entity to each step prevents missing out any points in data-collection - a factor many people are failing on !

Good luck and thanks for ur comments :-)

 

Anonymous Anonymous said ... (2:06 AM) : 

hi,
in the mnemonic, PAMHUGS FOSS SODAS, what does "SODAS" stand for?
i'm an img so im not to familair with mnemonics and stuff.
btw this site is a amazing....thanks for all ur help

 

Blogger Digitaldoc, MD said ... (11:45 AM) : 

Have now included that in the right side-bar, thanks for getting it to my notice. :-)

 

Anonymous samtam said ... (11:07 AM) : 

hey digidoc,

My mneumonics-
STOOLED for constipation causes
S h/o surgery, SC trauma,multiple Sclerosis

T Thyroid probs
O oxycodone(meds)
O occult bld(CA colon)
L low fibre diet
E excess Calcium
D diabetes(causing gastroparesis)

 

Anonymous Anonymous said ... (3:04 PM) : 

how to examine eyes for lid lag?

 

Blogger Digitaldoc, MD said ... (2:26 PM) : 

Lid Lag - Ask the SP to look up without moving the head up ...and then ask him to quickly look down with both eyes, keeping the head steady. The lids must move along with the eyeballs down..if there's a delay and they follow the eye-balls rather than move simultaneously - we got a lid lag !!

 

Blogger Digitaldoc, MD said ... (2:46 PM) : 

Lid Lag - Ask the SP to look up without moving the head up ...and then ask him to quickly look down with both eyes, keeping the head steady. The lids must move along with the eyeballs down..if there's a delay and they follow the eye-balls rather than move simultaneously - we got a lid lag !!

 

Blogger blog8181 said ... (12:50 AM) : 

After giving much thought in producing a productive and useful article on Multiple Sclerosis, we came up with this. Hope you find what you needed about Multiple Sclerosis in it.

 

Anonymous Anonymous said ... (7:34 AM) : 

Hi amazing website.Thanks a ton.
Can you help me with two quick questions
1. Where do you keep the stetho while taking history...is it ok to hang it around your shoulders just like most docs do or should I keep it in my labcoat pocket
2. Other than a case of alcoholism coming for evaluation or counselling in which other cases do we need to ask CAGE questionaire?

 

Anonymous Anonymous said ... (8:33 AM) : 

please tel me about enuresis history taking???

 

Anonymous Anonymous said ... (3:46 AM) : 

Hi Digitaldoc,
I passed mt CS. Thank you for your very helpful website.
Kim

 

Anonymous moin said ... (9:39 AM) : 

Hi Digidoc, I appriciate ur help to all CS candidate. First time visited, liked so much. Great job. Will try to help you out more in this If I can.
Dr Moin

 

Blogger Digitaldoc, MD said ... (1:25 PM) : 

Thank you everyone :-) ! g/l to all !

 

Anonymous Anonymous said ... (3:44 PM) : 

Hi Digitaldoc,

When you say "data-collection" what exactly do you mean?

Also, how did you go by asking all those questions for the practice cases in First Aid for CS? Did you memorize the questions and practiced and practiced interviewing a friend to the point it became automatic? Or did you go by the diseases in your differential and asked questions based on they symptomatology of each disease.

 

Blogger Digitaldoc, MD said ... (3:56 PM) : 

Hello. Data-Collection in the context of the Step 2 CS means positive and negative history-taking specific and relevant to the case in question.

Practicing the questions came by first memorizing the Differential Diagnoses and then practicing the cases with a partner - using the logic mentioned on this history-taking steps as a constant guide ..

..and yeah, it did become automatic at a point after I practiced talking for 6-8 hours a day with a partner who was extremely demanding and driving (If not for him, I would have been a lazy bum only reading and not acting it out..he he..hence a practice partner is great to have!)

 

Anonymous Anonymous said ... (3:11 PM) : 

is ten days of practice. like u said , 8-10 hours, enuf?? do we then need to spare time for revision, or is that it?

 

Blogger Digitaldoc, MD said ... (5:00 PM) : 

I had said 15 days - which would mostly include practice with a practice partner :-) and revision of theory details too

 

Anonymous Anonymous said ... (10:41 AM) : 

Dear D-doc: Could you post a sample case where you highlight the use of the steps above (especially 2-5?) This would help in understanding the diff between "OPD+details" and "data collection". If you have already done this, please provide the link (I can't find it so far)
Thanks a lot!!!

 

Blogger Digitaldoc, MD said ... (10:53 AM) : 

HI - thats a good point and in fact I have explained a case of heel pain as a sample. I shall put up the link to that within this post. THanks and g/l

 

Anonymous Anonymous said ... (11:33 AM) : 

hi i just wanted to know if while doin the physical exam do we have to tell the patient things like i have to look into your eyes for anychange in color or just that i need to look into your eyes same for nail do we have to tell him we r lookin for cahnge in color or shape or just tell him to see his nails same goes for everystep of the exam u know what i am talkin abt!!!

 

Blogger Digitaldoc, MD said ... (11:44 AM) : 

No - dont go into those clinical details - it will only evoke more questions and waste ur time. Be to the point.."Let's have a look at your eyes......could u look up for me.. ------etc."

 

Blogger sheraz said ... (11:51 AM) : 

S SMOKING
A ALCOHOL
D DRUGS

T TRAVEL
O OCCUPATION
N NUTRITION
E EXERCISE
S STRESS

 

Anonymous Hari said ... (4:43 PM) : 

Hey DigiDoc,
Thanks a million.
U R Tylenol for FMG and IMG..

I got this link for History taking. I thought it would be useful to others.

http://www.qub.ac.uk/cskills/video%20resource/GI%20history.htm

 

Blogger Digitaldoc, MD said ... (6:28 PM) : 

Hey guys - thanks for taking the time to share all this with readers :-) Good stuff !

 

Anonymous Anonymous said ... (1:55 PM) : 

hi doc, thank you so much for this great wonderful site.pls i need a quick answer to this- whenevr an SP tells us their presenting complaint , do i have to go " oh i am sorry to hear that"??

 

Anonymous Anonymous said ... (4:38 PM) : 

Dear Digital Doc,

This comes from a very thankful person who found your suggestions very useful in her exam. I have been a very silent reader of this blog. Took my cs in April and aced it, so I decided to come back and say thank you. Thanks very much and God bless you abundantly for taking out time to help people achieve their dream.

 

Blogger Digitaldoc, MD said ... (5:26 PM) : 

1. Yea, not a bad idea after the SP tells you his reason why he is there: "Oh I am sorry to hear that, that certainly does not sound good, let me go over a few questions with you and see how we can help"

2. Thanks ! and am glad you aced it :-) way to go ! g.l for the match

 

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  • Besides other history taking specific to the chief complaints that the patient has, use this mnemonic to remember specific data collection points:
    'SAFE GARD'

  • S- Safety @ home
  • A- Afraid of Hubby?
  • F- Family ? Friends aware ?
  • E- Emergency plan?
  • G- Gun @ home?
  • A- Alcohol?
  • R- Relationship with Hubby?
  • D- Drugs? Depression ?
  • If Depression = Yes - then proceed with data collection using Mnemonic 'FACE SLIPS' mentioned on this blog !
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