History Taking Skills

Grzegorz Chodkowski (MD)

Riga, Radisson SAS

2009
 History Taking Format

– Chief complaint
– History of present illness (HPI)
– Past medical history, which includes
• Childhood
• Medical
• Surgical
• OB/GYN
• Psychiatric
– Family history
– Medications
– Allergies
– Personal/social history
– Review of systems
Chief complaint
problem / condition that motivated patient to seek care

To elicit the chief complaint, ask broad questions:

– What brings you in today?

– Tell me what has been going on.
– What seems to be the problem?
– What are your complaints?
History of the present illness (HPI)

• Patient's age, sex, occupation

• Symptoms (or immediate cause of admission)
• Chronology and the seven characteristics of the
current symptoms:
-Anatomic location
-Quality
-Quantity or severity
-Timing
-Setting in which the symptoms occur
-Aggravating or relieving factors
-Associated symptoms
History of the present illness (HPI)
Use facilitating expressions to encourage the patient to
continue:
– Mmm Hmm.
– Yes?
– Uh Huh?
– And what else?
- I am with you
– Listening body language
 Once the patient has had a chance to tell his or her
story you can move on to more directed questions
to clarify.

• What is wrong?
• Where is it wrong?
• When did it start going wrong?
• How did it go wrong?
• Why do you think it is wrong?
Directed or closed questions
– Multiple choice

• Do you have nausea, vomiting, constipation or

diarrhea?
• Is the pain sharp, dull or shooting?
• Have you had this for days, weeks or months?
• How long is the pain: minutes or hours?

Important: Pause to wait for each response!!

Yes or No questions
• Do you have diarrhea every day?
• Do you have any allergies?

Quantitive questions
• How many loose stools do you have a day?
Remember !

Avoid leading questions

– You don’t smoke do you?
– You haven’t had any chest pain?
– Your wife is your only sexual partner, right?

Avoid compound questions

– Do you have trouble sleeping?
How much sleep do you get?
– Do you use cocaine, marijuana or alcohol?
 Mnemonics
L : Location
O : Other symptoms
C : Characteristic of the symptom
A : Aggravating or alleviating factors
T : Timing
E : Environment
S : Severity
 Location

• Where does it hurt?

• Which part of your chest/head/abdomen is
affected?
• Does it stay in one place or does it radiate
anywhere else?
Other symptoms

Pertinent positives and negatives to help

you rule in or rule out disease

Associated symptoms

Other new symptoms that may not be
related
 Other symptoms
- questions

• Apart from your chest problem are there any other problems
• How’s your appetite?
• Do you have any problems with passing water?
• Are your bowel motions regular?
• Have you noticed any blood in your stools?
 Characteristics
-quality of the symptom
Get the patient to use their own descriptive words if possible.

– What does it feel like?

– What kind of pain is it?
– Can you describe the pain?
– Does it affect your sleep/work?
– How often are the attacks?
– Is the pain continuous or does it come and go?
Aggravating And Alleviating Factors

– What makes it better?

– What makes it worse?
– What has the patient done to try to feel better?
– What seems to bring the pain on?
– Does anything make it better / worse ?
– Is the pain relieved by drugs / rest / changing position?
– Have you taken any medicines for the pain?
(over the counter medications, friend’s medication)
Timing: Onset & Duration

– When did it start?

– How long have you had this pain?
– When did you first notice it?
– Is it intermittent or continuous?
– How long does each episode last?
– Does the symptom vary with time of day?
– Have you ever experienced this before?
- Associations with specific events
Environment
– What places or events affect the symptom?
– Work vs. home
– Leisure activities
– Diet
– Emotions
– Heat, dust, altitude
Environment
– How is the symptom interfering with the
patient’s daily functioning?

– If the patient has pain, how bad is the pain

on a scale of one to ten?
Patient’s Interview
Past Medical History

– General state of health

– Chronic medical problems
– Hospitalizations
– Surgical history
– History of trauma
– Childhood illnesses
– Gynecologic history
– Health maintenance
Past Medical History

• Childhood illnesses
• Adult illnesses
• Medical conditions
• Surgeries
• Obstetric/gynecologic
• Psychiatric
 Past Medical History
Eliciting the Past Medical History

– How would you describe your health?

– Are you having any other problems with your health?
– Do you have any other medical problems?
– Are you treated for any other medicalconditions?

You may learn more about this with medications!

 Past Medical History
Medical Problems
Chronic problems like:
• Diabetes mellitus
• Hypertension
• Chronic back pain
• Depression
• Coronary artery disease or MI
• Congestive heart failure
 Past Medical History
Medical Problems Hospitalizations
– You can’t always accept the patient’s
diagnosis, use records to confirm.
When?
– Are any of these problems active? Where?
Why?
Childhood Illnesses For how long?
– Birth defects, ex., undescended testicle
– Attention deficit
– Drug use
– Anorexia
– Athlete
– Meningitis
– For Pediatrics information about the birth
is important
 Past Surgical History

• What part of the body?

• Why?
• When?
• Where?
• Any complications?
• Reactions to anesthesia?
 Past Surgical History – cont.
Trauma Pregnancies
What part of the body? • G = Gravida=pregnancies
How injured?
• P = Para = Live births
Where hospitalized?
Birth Control
Reproductive History
– Menstruation
• Start
• Length and frequency
 Medications

Health Maintenance

Immunizations

Screening Tests

Medications

Medicine name

Purpose

Dose

Route

Frequency

Side effects

Taking as prescribed?

Cost issues
 Medications - continued

Don’t forget!
– Over the counter drugs (OCD)
– Vitamins
– Nutritional supplements
– Any borrowed medications
 Known allergies
and resulting symptoms

e.g penicilllin rash

Medications
- What is the reaction?
Other substances, if severe reaction
– Ex. Peanut or bee sting allergy
 Social History

• personal status
• occupation
• education
• home conditions
• interests
 Family History
Major illnesses in the immediate family
(parents, grandparents, siblings)

Genetic diseases
– Sickle cell anaemia, cystic fibrosis

Familial diseases
– Type 2 diabetes, breast cancer

Psychiatric diseases
– Heritable
– Affect patient’s psychosocial environment

Contagious or Toxic
– Lead poisoning, influenza
 Sample Note Combining Time and Exam
• HPI: Mary Smith was seen in my clinic today. She presents with a right breast
lump which she noticed 2 weeks ago. The lump is quite firm. She denies weight
loss or nipple discharge. ROS: She has noticed some swollen lymph nodes in
her neck and axillary regions. Other systems are negative. PMHx: Her only
hospitalizations were for the births of her 2 children over 20 years ago. SHx:
She does not smoke or drink. FHx: Her mother had breast cancer and a
mastectomy.
• PE: Mary is healthy appearing. Her eyes clear. Oropharayngeal membranes
are pink and moist. Neck has good range of motion with no lymphadenopathy.
Heart has a regular rate and rhythm and lungs are clear to auscultation.
Abdomen is soft and non-tender. Breast exam revealed normal shape with no
skin discoloration. A solid mass was identified in the right breast with some
swelling of the axillary lymph nodes. She is alert and oriented x 3 and
neurologically grossly intact.
• Labs and x-ray: Mammogram reveals a 2 cm mass in the right breast. She also
has a small cyst in her left breast but no clear lymph node involvement.
• Impression: Otherwise healthy 46-year-old woman with right breast lump and
axillary lymph node swelling. Plan: Mary and her husband were at my office for
about 45 minutes and I spent 30 minutes talking to them about her prognosis and
risks and benefits of surgery. She agrees to breast biopsy with sentinel node
biopsy on Tuesday.
 Thank You!

Any Questions?