From Complete to Follow-Up: Exploring Types of History Taking in Primary Care

Patient history taking is a fundamental skill in clinical practice, enabling healthcare professionals to gather crucial information to guide patient management. In the UK, there are three main types of history taking: a complete patient health history, an episodic health history, and a follow-up health history.

Complete Patient Health History

A complete patient health history, also known as a comprehensive health history, is usually taken during a patient’s initial visit and serves as a basis for future care. It includes:

– **Presenting Complaint**: Detailed description of the patient’s main concern or reason for the visit. This includes the duration and severity of the symptom(s), any associated symptoms, and any self-treatment the patient may have tried.

– **History of Present Illness**: Chronological description of the development of the patient’s present illness from the first sign or symptom to the present. This includes the onset of the illness, the course of the illness (getting better or worse), any previous episodes, and any factors that make it better or worse.

– **Past Medical History**: Information about the patient’s past illnesses, surgeries, injuries, allergies, and medication use. This includes both childhood and adult illnesses, both acute and chronic conditions, hospitalizations, accidents, and treatments received.

– **Family History**: Health information about the patient’s close family members. This includes any hereditary diseases, as well as the health status or cause of death of immediate family members.

– **Social History**: Information about the patient’s lifestyle, such as occupation, living conditions, diet, exercise, smoking, and alcohol use. This also includes the patient’s sexual history, travel history, and any exposure to environmental hazards.

– **Review of Systems**: Systematic review of each body system to identify any symptoms not previously mentioned. This includes a review of symptoms related to all major body systems, including the cardiovascular system, respiratory system, gastrointestinal system, nervous system, musculoskeletal system, and skin.

Episodic Health History

An episodic health history is focused on a specific problem or episode of illness. It is often used in acute care settings or when a patient presents with a new issue in primary care. It includes:

– **Presenting Complaint**: Detailed description of the patient’s current issue. This includes the duration and severity of the symptom(s), any associated symptoms, and any self-treatment the patient may have tried.

– **History of Present Illness**: Detailed account of the current problem, including onset, duration, character, aggravating and relieving factors, and associated symptoms. This includes a detailed description of the symptom(s), any changes in the symptom(s), and any factors that make it better or worse.

– **Past Medical History**: Relevant past health information related to the current issue. This includes any previous episodes of the same or similar problem, any related illnesses or surgeries, and any related treatments received.

– **Targeted Review of Systems**: Review of symptoms related to the body system involved in the current issue. This includes a review of symptoms related to the specific body system(s) involved in the patient’s current problem.

Follow-Up Health History

A follow-up health history is taken when a patient returns for a review after initial assessment and management. It focuses on changes in the patient’s condition and response to treatment. It includes:

– **Interval History**: Information about any new events or changes in the patient’s condition since the last visit. This includes any new symptoms, any changes in existing symptoms, any new diagnoses, and any changes in treatment.

– **Review of the Initial Problem**: Assessment of the progress of the initial problem, including any changes in symptoms. This includes a detailed description of the current status of the initial problem, any changes since the last visit, and the patient’s response to treatment.

– **Treatment Review**: Evaluation of the patient’s response to treatment, including any side effects. This includes a review of the effectiveness of the treatment, any side effects experienced, and the patient’s adherence to the treatment plan.

– **Plan Review**: Review and update of the management plan based on the patient’s progress and current condition. This includes a review of the current management plan, any changes needed, and plans for future care.

Understanding the different types of history taking and their appropriate use is crucial for effective patient management in primary care. It allows healthcare professionals to gather relevant information, make accurate diagnoses, and provide effective treatment.

We highly recommend the article “Physical Examination Techniques for Health Care Professionals” on the Professional Development UK (PDUK) website. This resource provides valuable insights and practical guidance that can complement the knowledge shared in this piece and can be an excellent guide for healthcare professionals seeking to enhance their skills in physical examination. Check it out at the provided URL.

References

Bates, B., 2020. Bates’ Guide to Physical Examination and History Taking. Wolters Kluwer.

Epstein, O., Perkin, G.D., Cookson, J., Watt, I.S., Rakhit, R., Robins, A.W. and Hornett, G.A., 2018. Clinical Examination. Elsevier Health Sciences.

Swartz, M.H., 2020. Textbook of Physical Diagnosis: History and Examination. Elsevier Health Sciences.

Talley, N.J. and O’Connor, S., 2020. Clinical Examination: A Systematic Guide to Physical Diagnosis. Elsevier Health Sciences.