Obtaining an accurate medical history is an essential part of your job as a Medical Assistant. Whether the patient is new to the practice, or an established patient, it is very important to obtain the history that is relevant to the patient’s chief complaint. For example, you have an established patient who is presenting to the clinic for complaints of abdominal pain. You research the chart but do not see an adequate history that might help the doctor diagnose the patient. What questions might you ask the patient regarding abdominal pain? Let’s say for this lesson that the patient is a 35 year old female.
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Medical Talk 
Apr 16, 2014 @ 16:13:29
Ask open questions and give the patient time to elaborate. However, it is very important to ascertain that you are ‘speaking the same language’. Avoid technical terms, jargon or abbreviations. Make sure that you understand what the patient means and get amplification of specific points. To patients, the word ‘stomach’ can mean anywhere from the diaphragm to the groin and includes the genitals. ‘Do you have a hard stool?’ may make the patient wonder if the chair in the kitchen is comfortable. Does ‘coughing up blood’ mean haemoptysis or haematemesis? Patients often describe pain as ‘chronic’, meaning severe rather than of long-standing duration.
Apr 21, 2014 @ 15:34:29
I would say the first thing to ask her is when her last menstrual period was. Could she be pregnant? What other symptoms has she had, such as, nausea, vomiting and/or diarrhea? When was her last Pap/pelvic exam and what were the results? I would think finding out how long the symptoms have been happening, and if they’re constant or come and go would be important as well. Has she ever been diagnosed with any abdominal diseases, such as; gallstones, any type of cancer (stomach, liver, pancreatic etc) Does any of those kinds of cancer run in her family? What about any kind of female cancers such as; cervical, uterine or ovarian? Is there any history of endometriosis in her family.