HISTORY TAKING IN MEDICINE

Dr. Asraf Hussain

MD, Internal medicine
Lecturer , National medical college Birgunj , Nepal.
The “ Classic” History Taking Sequence
Identification Functional Inquiry ( System
Review)
Previous Admission
Personal History
Chief Complaints
Family History
History of Present Illness
Physical Examination
Past Illness
Summary

Differential Diagnosis
 Remember !!!
“ First step of your history taking determine 70% of etiology”
● Rapport : introduce yourself in a warm , friendly manner ,Maintain good eye contact , Listen
attentively, touch patient appropriately ,Facilitate verbally and non-verbally , discuss patients personal
concerns , questioning - simple , clear, avoid medical terms and Leading questions.
● Previous admission -List of hospitalization in the order they occurred ,Specify the date
,Name and location of the hospital ,Disease that led to admission ,Outcome as briefly as is possible.

Medical record : legal documents in many jurisdictions.

● Identification : @NASOAH - Name; Age: Sex: Occupation:

Address: Religion: Hospital number.

 Chief complaints
Sign/Symptoms - prompting patients to seek medical advice .

● Duration of each sign and symptom,More than one complaint, they should be listed in the chronological order.
● Often usef ul to start by the patients was perfectly well until ….course duration , character , location , exacerbation,
tenderness, perfect of t/t; negative-positive statements.

Past illness :Listing of illness unrelated to the present illness, experienced in the past.

➢ Including childhood diseases.

➢ Serious injuries and surgery not requiring hospitalization.
➢ Mention of each disease with an approximate date, severity, duration, complications and sequel (consequences) is
essential.
 Systemic review

1. Functional Inquiry (system Review)- Detailed account of signs and symptoms referable
to each system of the body.
2. it gives a clear understanding of the history of the present illness .
3. double check on the history of the present illness.
4. it will permit the examiner to group signs and symptoms that need to be considered
with the present complaints.
5. it will guide the examiner to concentrate on specific systems during the physical
examination
 Systemic review cont….

HEENT =Head, Ears, Eyes, Nose, Mouth and Throat .

Head : Headache, injury

Ears: Pain or earache, deafness, discharge, vertigo, tinnitus.

Eyes: Disturbance of vision, pain in the eyes or orbit, eye-strain, lacrimation, photophobia, itching.

Nose: Frequent head colds, epistaxis, discharge, hay-fever, sinusitis.

Mouth and throat: Teeth (dental hygiene), bleeding gums, sore tongue,tonsillectomy, sore throat.

Glands :Enlarged glands, Lumps in the breasts, discharge from the nipple, Goiter with or without heat
or cold intolerance ,Undescended or swollen testicles.
 Systemic review cont…...

Respiratory system: Cough Expectoration (amount, colour, odour) ,Haemoptysis ,Chest pain ,Shortness
of breath, Wheezing or asthma ,Cyanosis.

Cardiovascular system: Dyspnoea (degree of exercise tolerance) ,Palpitation, Orthopnoea (number of

pillows required) ,Paroxysmal nocturnal dyspnoea ,Swelling of the feet, Chest pain ( with character, location
and radiation) ,Syncope, Stridor ,Hypertension.

Gastrointestinal system: Appetite, Nausea, Vomiting, Dysphagia, Food idiosyncrasy, Heartburn,

Abdominal pain, Bowel habits, Jaundice, Bloody, tarry or clay-colored stools , Hemorrhoids.
 Systemic review cont…...

Genitourinary system: Flank pain (steady, colicky, etc.), Frequency of urine (express the day to night ratio as D/N=
----),Dysuria, urgency, hesitancy, dribbling, haematuria, pyuria, incontinence, Venereal disease , Menstrual history :
Record as “menarche/interval between periods/duration of flow/amount of flow” ,e.g. 14/28/5 prof use, moderate or
normal menopause (mention if there are postmenopausal symptoms).

Integumentary system: (skin, hair and nails) Dry or moist skin , Rashes, Ulcers, Urticaria, Hair distribution,
Pigmentary changes, Changes in fingernails.

Allergy : Infantile eczema, Drug sensitivity , Urticaria, Hay Fever, Asthma , Serum sensitivity

Locomotor system: (musculo-skeletal system) Bony deformities, Joint pain or swelling,Limping, Loss of f unction of
limbs or joints, Muscle weakness or wasting, Leg-swelling like elephantiasis.
 Systemic review cont…...

Central nervous system (CNS): Poor memory, Lack of orientation, Seizures, Vertigo, Diplopia,
Anesthesia, Hyperesthesia, Insomnia, nervous breakdown.

Personal History
❖ Early development: place of birth and early homes, childhood development, health and activities,
social and economic status.
❖ Education: School history, achievements and failures. • Social activities: Recreation and other
activities.
❖ Work record: Age begun, type of work, number of jobs (mention success or failure regarding shift of
jobs), industrial hazards and exposures, present work.
❖ Environment: living conditions.
❖ Habits: Dietary, alcohol, tobacco,drugs,herbs (including anthelmintics).
❖ Marital status: Health of wife (or husband), adjustment, number of children and their health.
 Systemic review cont…...

Family History : Father and mother: Age ,health, date and cause of death. Siblings: List with ages, health ( if
dead, mention cause of death) Family disease: Tuberculosis, diabetes mellitus, hypertensive disorders, migraine.

Social history : smoking history - amount ,duration,types . Alcohol :amount duration types , Occupation ,
social class , home conditions: water supply ,sanitation, animals ,birds, pp his/her house

S-Subjective

O- objective

A-address each active problems after making … make d/d…

P -plans, medicine, treatment , investigations ,follow up..

 Special review
@OPQR3ST

P-position / site

Q-quality nature , character -burning , sharpness, stabbing,throbbing , Depth of pain -superficial

or deep .

R- relationship to anything or other body f unctions / position.

Radiation

Relieving or aggravating factors

 Special review cont…
Severity - how it affect daily work / physical activities . wake up at night , cannot sleep/
do any work .

Timing - Mode of onset- abruptly/ gradually ,progression ( continuous or intermittent

-if intermittent - frequency and nature .

Treatment :

Associated symptoms:
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