HISTORY TAKING:

- FIRST THING when taking a history -> get CONSENT.

- Make sure the patient is comfortable (doesn’t always have that luxury in a clinical setting)

- NB: If it’s another person you’re taking the history from -> you say the historian is the Patient
plus so and so or the patient is unconscious, history taking from whoever.

- Most of the times, the history is taken from the casualty officer on the wards -> acute setting

- Establish Patient’s Name, Age, Occupation.

- Ethnicity -> more important for when writing the examination.

- For the history -> more important to know their religion -> especially if they’re jehovah’s
witnesses -> that must be stated up front.

o The other religious denominations doesn’t really play a major risk factor unless they’re a
strict vegetarian.

TIPS FOR HISTORY TAKING:

Chest pain – one of the most common presenting complaints.

- One major part of the history – looking at differentials – what differentials that chest pain could
have.

o In the HPC – it is very important that you must know what differentials are – for
example – chest pain doesn’t have to be ischemic heart disease or acute coronary
syndrome alone.

o A chest pain could also be a:

 Pulmonary embolism

 Gerd related

 Musculoskeletal

o Therefore, a broad differential for chest pain, but when you are showing that you are
taking a history to rule out those differentials -> that’s what makes a good HPC.

o DON’T ASK THE PATIENT IF THEY HAVE THE DISEASE AS PATIENT MIGHT NOT HAVE BEEN
DIAGNOSED WITH IT AND HENCE DON’T KNOW THE DISEASE. YOU MUST THEREFORE
ASK THE PATIENT IF THEY HAVE BEEN EXPERIENCING SPECIFIC SYMPTOMS OF THE
DISEASE THAT YOU WANT TO CONFIRM OR RULE OUT.

o Don’t confuse complications and etiology.

 Eg. Complications of the hypertensive heart disease -> orthopnea, pnd, pedal
edema.
  Therefore, not saying what the etiology is.

- In addition to ruling out differential diagnosis, risk factors are important.

o Must have supporting risk factors for the condition you have in mind

- Complications is another key part.

o So if someone has chest pains -> want to know if they have orthopnea, pnd, pedal
edema -> which is more in keeping with congestive cardiac failure -> which is
complication of an MI

o Aortic dissection -> the patient shouldn’t be having pedal edema or orthopnea. Instead
they would have symptoms of shock -> hypovolemic shock if it’s severe enough.

- SOCIAL HISTORY

o Patient has two story house with running water, electricity and good garbage disposal
facilities. (That’s not a social history alone)

o A social history, apart from the illegal drugs, smoking and alcohol, is how the social
aspect of the disease impacts on the patient and vice versa.

 Social aspect of the disease affects the patient:

 Social history becomes very important in a respiratory case where you

need to know what the environment is in the home, outside the home,
in the workplace, outside the workspace.

 The disease affects the social aspect of the patient:

 If the patient is the only breadwinner for the family, then it’s going to
put an entire family in poverty and at risk -> being poorer puts you at a
poorer health state.

 If someone has chest pains and there’s no bedroom upstairs, they can’t
go up the stairs.

 Someone has diabetes and they don’t have a fridge or they have
irregular electricity supply, so they can’t store their insulin

o That’s what meant for a social history. Therefore, you need to always find out how this
person interacts with the rest of the family and how this disease is going to impact on
them. Do they have medical insurance? If they have an amputation, can they manage at
the home?

- SCREENING HISTORY – DON’T NEGLET TO TAKE IT

o If the patient is over 50, have they ever done a mammogram?

o Over 50, have they ever done a colonoscopy?

 o Is there is a family history of colon cancer, then they need to do the colonoscopy, not at
age 50 but 10 years before their relative presented with cancer.

o Revise screening rules:

 Mammograms

 Colon cancer

 Prostate cancer

 Breast cancer

- MEDICINE HISTORY – NOT JUST DRUGS

o It is:

 Over the counter drugs

 Herbal supplements

 Dietary supplements