History – 101 Basic Structure

A comprehensive medical history is a crucial element of patient assessment in clinical practice. It enables doctors to understand a patient’s condition, formulate differential diagnoses, and plan appropriate management. The mnemonic PRoMPF STOPI can be used to remember the 10 items required.

Note that with the presenting complaint items 4-10 apply to almost all conditions, not just pain.

  1. Presenting Complaint (HPC) (SCR ODT EAS – PT)
    1. Site: Where in the body are the symptom(s) experienced?
    2. Character: Description of the primary symptom(s) or reason for seeking medical care.
    3. Radiation: Whether the symptom(s) spread to other areas.
    4. Onset: When the symptom(s) began or were first noticed.
    5. Duration: How long the symptom(s) have been present.
    6. Temporal Pattern: Any pattern or timing to the symptom(s), such as nocturnal or postprandial.
    7. Exacerbating/Relieving Factors: What makes the symptom(s) better or worse.
    8. Associated Symptoms: Other symptoms that accompany the main complaint.
    9. Severity: The severity of the symptom(s), often quantified (e.g., on a scale of 1-10).
      • How has this <problem> impacted your life?
    10. Patient Thinks: What does the patient think is going on?
  2. Review of Systems (RoS):
    • A systematic inquiry about symptoms the patient may be experiencing related to each major body system (e.g., cardiovascular, respiratory, gastrointestinal, neurological).
    • Red flags should be checked as part of the system review.
  3. Medication History (MHx):
    • We should gather the BPMH (Best Possible Medication History)
    • Current medications (prescription, over-the-counter, herbal supplements), including dosages and frequency.
    • Compliance with these medications.
    • Barriers to compliance
    • Known drug allergies or adverse reactions to medications.
  4. Past Medical History (PHx):
    • Chronic conditions, acute illnesses, hospitalizations, surgeries, injuries, and significant illnesses in the past.
  5. Family History (FHx):
    • Health status or causes of death of immediate family members.
    • Presence of any hereditary conditions or diseases common in the family.
  6. Social History (SHx):
    • Occupation and educational background.
    • SNAP lifestyle factors
      • Smoking
      • Nutrition
      • Alcohol and other drugs
      • Physical exercise
    • Living situation and significant life events.
    • Hobbies and recreational activities.
    • Sexual history, relationships, and practices.
  7. Travel and Exposure History (THx):
    • Recent or frequent travel, exposure to infectious diseases, or environmental hazards.
  8. Obstetric/Gynecological/Sexual History (OHx):
    • For female patients, details about menstrual history, pregnancies, childbirths, and gynecological conditions.
    • For male patients, prostatism and ED.
    • For both sex and STDs.
  9. Psychiatric History (PsychHx):
    • History of mental health conditions, treatments received, and hospitalizations.
  10. Immunization and Preventive Care History (IHx):
    • Records of vaccinations
    • Records of screening tests (e.g., mammography, CKD, CST, CVD, DEXA, DM, FOBT, PSA).

Collecting a thorough medical history is foundational for effective patient care, allowing for an informed approach to diagnosis and management.