Richard Rathe, MD

Associate Professor of Family Medicine (ret.) and Medical Informatician

A Guide to Medical History Taking

By •• Posted in Medicine, Teaching

Always start with the standard questions applied to the patient’s Chief Concern(s): Location/Radiation; Quality/Severity; Duration (total/episode)/Frequency; Aggravating/Relieving Factors; Associated Symptoms/Effect on Function.

It is useful to think of the secondary history as a Focused Review of Systems (ROS). These questions often bring out information that supports a certain diagnosis or helps gauge the severity of the disorder. Unlike the primary history, a certain amount of interpretation (and experience) is necessary.

The tertiary history brings in elements of the Past Medical and Family History that have a bearing on the patient’s condition. By the time you get to the tertiary history you may already have a good idea of what might be going on. Read More…

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