➢ Clinical History

➢ Clinical Examination
➢ Laboratory Investigation

Dr. Imad H. Tahir – Senior consultant of internal medicine. Clinical history taking. 2020 - 2021
Dr. Imad H. Tahir – Senior consultant of internal medicine. Clinical history taking. 2020 - 2021
Before taking the clinical history you have to:
✓ Stand or sit at the right side of the patient
✓ Greet the patient
✓ Introduce yourself to the patient
✓ Take a permission from the patient to start the clinical
history taking
✓ Keep one meter distance between you and the patient
✓ Keep eye contact with the patient while he/she answering
your questions
✓ You have to thank the patient after finishing the history
taking

Dr. Imad H. Tahir – Senior consultant of internal medicine. Clinical history taking. 2020 - 2021
❖ Personal history
❖ Chief compliant and its duration
❖ History of present illness
❖ Review of systems
❖ Past medical history
❖ Past surgical history
❖ History of previous admission to hospital
❖ History of blood transfusion
❖ Drug history and Allergy
❖ Family history
❖ Social history
❖ Menstrual history
❖ Psychiatric illness history

Dr. Imad H. Tahir – Senior consultant of internal medicine. Clinical history taking. 2020 - 2021
We ask about the patient’s:
✓ Name ( identity to the patient)
✓ Age or birth date ( some diseases occurr only in pediatric age
group like febrile convulsion which is only occur in children
less than 5 years old. Other diseases occur most commonly in
middle and old age group patients like coronary heart
diseases and cerebrovascular diseases ).
✓ Sex or gender (some diseases occur most commonly in female
like systemic lupus erthymatosus SLE, other connective
tissue diseases, and autoimmune diseases. While other
diseases occur in male like hemophilia A ).

Dr. Imad H. Tahir – Senior consultant of internal medicine. Clinical history taking. 2020 - 2021
✓ Occupation or job
▪ The job of the patient may be a cause of his disease, for
example veterinary doctors more liable to brucellosis.
▪ It May aggravates the patient illness, for example dusty
workplace may precipitate asthmatic attack in patients with
bronchial asthma.
▪ Sometime we may help the patient by writing a medical
report to change his/her job if the job proved to be an
aggravating factor for his/her disease or to help him to get
financial compensation if the job causing serious disease like
malignancy.

Dr. Imad H. Tahir – Senior consultant of internal medicine. Clinical history taking. 2020 - 2021
✓ Address or residency ( where is the patient living ? )
❑ Some diseases are endemic in the region where the patient live
like enteric fever in the south of Iraq and malaria in the north of
Iraq.
❑ Some diseases are epidemic in the region where the patient live
like vibriosis ( cholera ) epidemic for example.
✓ Marital status ( some diseases transmitted from one partner to the
other like sexually transmitted diseases STD ).
✓ Next of kin or companion ( the patient may be unconscious or
mentally retarded , so his next of kin may help us to take
information about the patient illness).

Dr. Imad H. Tahir – Senior consultant of internal medicine. clinical history taking. 2020 - 2021.
✓ Religion ( some diseases are more common in Christians like
alcoholic related diseases and diseases related to pork meat
eating like diseases caused by Taenia solioum ( cysticercosis ).
✓ Way of bringing the patient to hospital ( when brought by
ambulance, this mean the illness is serious unlike the patient who
is coming ambulating to hospital ).
✓ Date of admission to hospital.
✓ Mobile number (for communication )
✓ e-mail ( for communication )

Dr. Imad H. Tahir – Senior consultant of internal medicine. Clinical history taking. 2020 – 2021.
 It is the main suffering or sufferings that
brought the patient to hospital or to consult
his or her doctor.
Dr. Imad H. Tahir – Senior consultant of internal medicine - clinical history taking. 2020 – 2021.
❖ Avoid using technical ( medical terms ), for examples say:
pain in the head instead of (headache)
frequent bowel motion instead of (diarrhea)
loss of consciousness instead of (coma)
nasal bleeding instead of (epistaxis)
inability to pass stool instead of (constipation)
joint pain instead of (arthralgia)
❖ The most common chief complaint is pain ( whatever its site: chest,
abdomen, head, muscle, joint, back pain, and others ).
❖ When talk about the duration of chief complaint: say, for example (if the
duration of abdominal pain is 10 days):
Abdominal pain of ten days duration. or
Abdominal pain since ten days. or
Abdominal pain for ten days.
Dr. Imad H. Tahir – Senior consultant of internal medicine - clinical history taking. 2020 – 2021.
➢ It is the story of the patient illness.
➢ When you present this story, use the patient own words.
➢ Avoid using technical (medical ) terms.
➢ Start with the sentence (the story started since
“duration” when the patient began to suffer from ).
➢ Ask about the last time where the patient was healthy .
➢ Ask, is it a new problem(first time having this problem)
➢ Use judgment depending on the chief complaint of the
patient.

Dr. Imad H. Tahir – Senior consultant of internal medicine - clinical history taking. 2020 – 2021.
❑ Talk about the patient’s chief complaint in details.
❑ Talk about the associated symptoms.
❑ Talk about , what the patient did? Is the patient consulted
his/her doctor? Does he/she called the ambulance to transfer
him/her to hospital? Does the patient brought by his/her next
of kin to the emergency room?
❑ Talk about, what the doctor did for the patient? When
admitted him/her to hospital? Which investigations were
done for the patient? Which sort of treatments were offered
for the patient?
❑ How the patient is doing now?
Dr. Imad H. Tahir – Senior consultant of internal medicine - clinical history taking. 2020 – 2021.
❑ Site: where it is located on the body?
❑ Radiation: to which site it is transferred?
❑ Quality: (dull, burning, tightness, stabbing “knife-like”, pressure,
colicky, tingling…etc).
❑ Onset: either sudden (abrupt) or gradual in onset
❑ Timing: when did the pain start and for how long has it been going on.
❑ Character: is the pain intermittent or constant? If intermittent, ask:
How long does it last?
How often does it occur?
❑ Severity or intensity: Does the pain mild, moderate, or sever?
❑ Alleviating/aggravating factors:
alleviating (relieving) factors: mean( what relief the pain).
aggravating (precipitating) factors: mean(what make the pain worse).
❑ Does the pain affect the patient sleep?
❑ Does the pain affect the patient daily activity?

Dr. Imad H. Tahir – Senior consultant of internal medicine - clinical history taking. 2020 – 2021.
➢ Ask about the cardinal symptoms for each body
system.
➢ Move from the head to toes when you asking
questions.
➢ Mention the positive symptoms at first and then the
negative one.
➢ do not repeat things already answered as part of the
HPI.
Dr. Imad H. Tahir – Senior consultant of internal medicine - clinical history taking. 2020 – 2021.
 General Neurological Cardiovascular

Gastrointestinal Breasts Respiratory

Genitourinary Musculoskeletal Endocrine

Eyes Skin Hematology

ENT Psychiatric

Dr. Imad H. Tahir – Senior consultant of internal medicine - clinical history taking. 2020 – 2021.
 GENERAL

❖Fever/Chills/Night sweats.
❖Appetite & weight changes.
❖Fatigue/Tiredness.
❖sleep. Disturbances.

Dr. Imad H. Tahir – Senior consultant of internal medicine - clinical history taking. 2020 – 2021.
 NEUROLOGICAL

✓ Headache (detail its criteria as it is a type of pain).

✓ Dizziness / vertigo.
✓ Loss of consciousness / Fainting(Syncope) / Blackouts / Coma.
✓ Seizures (Convulsions).
✓ Tremor/Titubation/Flapping tremor.
✓ Blurring of vision/ double vision.
✓ Limbs weakness/Hemiparesis/Mono-paresis/Para-paresis/Tetra-paresis.
✓ Walking ability/Steadiness.
✓ Numbness/ Tingling(Paraesthesia)/Anaesthesia/Trembling/Burning
sensations.
✓ Memory loss/poor concentration.
✓ Behavioral changes.

Dr. Imad H. Tahir – Senior consultant of internal medicine - clinical history taking. 2020 – 2021.
 CARDIOVASCULAR

❑ Chest pain(details)/Chest discomfort.

❑ Palpitation (patient awareness of his/her cardiac beats).
❑ Cyanosis.
❑ Shortness of breath(at rest or on exertion)/Orthopnea (0n lying
flat)/Paroxysmal nocturnal dyspnea (PND)/Trepopnea (on lying on
one side)/Platypnea(orthostatic dyspnea, on standing or sitting).
❑ Syncope.
❑ Hemoptysis.
❑ Leg swelling(edema).
❑ Intermittent claudication/Leg cramps.
❑ Color changes in fingers/toes on cold exposure.
❑ Loss of hair on extremities/Cold extremities/Discoloration of
extremities/Varicose veins/Leg ulcers.

Dr. Imad H. Tahir – Senior consultant of internal medicine - clinical history taking. 2020 – 2021.
 RESPIRATORY

o Blocked nose/Runny nose/Sneezing.

o Sore throat/Change in voice.
o Strider/Wheeze.
o Cough(dry/productive). If productive(wet) cough, then ask
about:
o Sputum (color, quantity, odor, presence of blood).
o Hemoptysis.
o Chest pain (detail the its character if present).
o Dyspnea at rest/Dyspnea on exertion/Orthopnea.
o Cyanosis.

Dr. Imad H. Tahir – Senior consultant of internal medicine - clinical history taking. 2020 – 2021.
 BREASTS

❖Breast pain (details if there is a

pain)/Breast discomfort.
❖Any tenderness (pain on touch).
❖Any lumps.
❖Any nipple discharge/Galactorrhea.
❖Any self examination.
❖Any previous mammogram.
Dr. Imad H. Tahir – Senior consultant of internal medicine - clinical history taking. 2020 – 2021.
 GASTROINTESTINAL
✓ Any sores on lips, mouth, and tongue.
✓ Any teeth /Gum problems.
✓ Any gum bleeding.
✓ Any thrush.
✓ Water brash (excessive salivation).
✓ Regurgitation
✓ Anorexia/Weight loss
✓ Dysphagia/Odynophagia.
✓ Heartburn/Dyspepsia.
✓ Indigestion.
✓ Abdominal pain(details).
✓ Abdominal distension(bloating)/Flatulence/Flatus.
✓ Nausea/Vomiting (content of the vomitus)/Diarrhea (content of stool and if there is any
blood with stool)/Constipation.
✓ Change in bowel habits.
✓ Change in stool appearances/Steatorrhea(fatty stool).
✓ Anal pain/Anal itching/Tenesmus (ineffectual and painful straining at defecation).
✓ Hematemesis/malena/Hematochezia/Bleeding per rectum(fresh blood).

Dr. Imad H. Tahir – Senior consultant of internal medicine - clinical history taking. 2020 – 2021.
 GENITOURINARY

➢ Polyuria / Nocturia / Oliguria / Anuria.

➢ Dysuria Frequency / Urgency / Hesitancy.
➢ (pain/burning on urination).
➢ Flank (loin) pain (details).
➢ Straining / Incontinence.
➢ Dribbling of urine / Narrow stream urine.
➢ Urinary retention.
➢ Change in color/odor / Hematuria.
➢ Stones passage in urine.
➢ Genital discharge.
➢ Genital itching / Genital sores / Ulcers.
➢ Testicular swelling.

Dr. Imad H. Tahir – Senior consultant of internal medicine - clinical history taking. 2020 – 2021.
 MUSCULOSKELETAL

Ask about:
❑ Muscle pain (myalgia).
❑ Muscle tenderness.
❑ Joint pain (arthralgia).
❑ Joint swelling / Joint tenderness / Joint hotness
❑ Backache.
❑ Bone pain.
❑ Walking difficulty.
❑ Neck stiffness.

Dr. Imad H. Tahir – Senior consultant of internal medicine - clinical history taking. 2020 – 2021.
 ENDOCRINE
❖ Heat/cold intolerance.
❖ Excessive sweating.
❖ Tremor.
❖ Fatigue / Tiredness.
❖ Polyuria / Thirst / Polydipsia / Hunger.
❖ Weight gain/ loss.
❖ Appetite.
❖ Change in hair distribution/coarseness.
❖ Breast changes.
❖ Menorrhagia / Oligomenorrhea / Amenorrhea.
❖ Fertility.
❖ Change in ( hat/glove/shoe )size.
❖ Skin discoloration.

Dr. Imad H. Tahir – Senior consultant of internal medicine - clinical history taking. 2020 – 2021.
 SKIN
Ask about:
➢ Rashes.
➢ Hives.
➢ Lumps.
➢ Ulcer.
➢ Itching.
➢ Dryness.
➢ Changes in skin/hair/nails.
Dr. Imad H. Tahir – Senior consultant of internal medicine - clinical history taking. 2020 – 2021.
 HEMATOLOGY
Ask about:
❑ Bleeding.
❑ Easy bruising.
❑ Blood clots.
❑ Pruritus.
❑ Fever.
❑ Sweating.
❑ Weight loss.
Dr. Imad H. Tahir – Senior consultant of internal medicine - clinical history taking. 2020 – 2021.
 EYES

Ask about:
✓ Blurring of vision.
✓ Double vision (diplopia).
✓ Photophobia / Excessive lacrimation / Itching
✓ Visual loss / Blind spot.
✓ Ocular pain / Eye redness.
Dr. Imad H. Tahir – Senior consultant of internal medicine - clinical history taking. 2020 – 2021.
 ENT
Ear. Ask about:
❑ Hearing / Hearing aid.
❑ Tinnitus (ringing in ears ).
❑ Dizziness / Vertigo.
❑ Ear pain. Drainage (discharge).
Nose. Ask about:
❑ Blocked nose / Runny nose (rhinorrhea) / stuffiness / postnasal drip.
❑ Itching / Dryness / Nasal bleeding (epistaxis) / Sinus pain.
❑ Anosmia (loss sense of smell).
❑ Hyperosmia (enhanced sense of smell).
Throat. Ask about:
❑ Sore throat.
❑ Hoarseness of voice / voice changes.

Dr. Imad H. Tahir – Senior consultant of internal medicine - clinical history taking. 2020 – 2021.
 PSYCHIATIC
Ask about:
❖ Emotional distress.
❖ Nervousness.
❖ Anxiety.
❖ Fear.
❖ Insomnia.
❖ Mood changes.
❖ Personality changes
❖ Hallucinations/delusions.
Dr. Imad H. Tahir – Senior consultant of internal medicine - clinical history taking. 2020 – 2021.
 History of chronic diseases

Past surgical history

History of blood transfusion

History of previous hospitalization

Dr. Imad H. Tahir – Senior consultant of internal medicine - clinical history taking. 2020 – 2021.
Ask about diseases like:
❖ Hypertension.
❖ Diabetes mellitus.
❖ Ischemic heart disease (IHD).
❖ Cerebrovascular disease.
❖ Bronchial asthma.
❖ Peptic ulcer.
❖ Epilepsy.
❖ Malignancy.
❖ Others, like connective tissue diseases.
Dr. Imad H. Tahir – Senior consultant of internal medicine - clinical history taking. 2020 – 2021.
➢ Ask about any history of previous surgical
operation.
➢ Mention the name of surgery and its date.
➢ If no history of any surgery ... tell that the
patient has no history of previous surgical
operation.
➢ Ask about any history of previous trauma
or injury.
Dr. Imad H. Tahir – Senior consultant of internal medicine - clinical history taking. 2020 – 2021.
❑Ask about any history of blood
transfusion.
❑If no history of blood transfusion … Say
that, the patient hasn’t any history of
blood transfusion
❑If the patient has a history of blood
transfusion, then tell how many times?
and what is the reason beyond each blood
transfusion?
Dr. Imad H. Tahir – Senior consultant of internal medicine - clinical history taking. 2020 – 2021.
✓ Ask about any history of previous admission to
hospital.
✓ If no history of previous admission to hospital,
then say that there is no history of previous
hospitalization.
✓ If the patient has a history of previous
admission to hospital … Tell, how many times
he was admitted? What is the reason beyond
each admission.
❖ Ask about any history of chronic drug use.
❖ Ask about any history of recently used drugs.
❖ Ask about the name, frequency (how many times per day)
and dosage of each drug.
❖ Ask about the patient compliance (adherence to his / her
treatment).
❖ Ask about herbal medicine use.
❖ Ask about immunization status.
❖ Ask about any allergy to penicillin, sulfa drugs, aspirin and
any other drugs.
❖ Ask about any allergy to food.

Dr. Imad H. Tahir – Senior consultant of internal medicine - clinical history taking. 2020 – 2021.
❖ Ask about similar patient’s symptoms or condition in
the family.
❖ Ask about chronic diseases in the family.
❖ Ask about hereditary diseases in the family.
❖ Ask about premature death in the family.
❖ Ask about infectious diseases in the family like viral
hepatitis and pulmonary tuberculosis (T.B).
❖ Ask about atopic (allergic) diseases in the family like
bronchial asthma, allergic rhinitis (hay fever) and
eczema.

Dr. Imad H. Tahir – Senior consultant of internal medicine - clinical history taking. 2020 – 2021.
Ask about:
❑ Living situation (housing). Ask about: The site of living
(urban or rural), number of bed rooms, number of the
family members, water supply (tap or distil water),
electricity, sanitation, ventilation).
❑ Is he / she dealing with animals (pets) or not.
❑ Type of diet that the patient usually eat (is there any
special diet).
❑ Ask about hobbies and recreation.

Dr. Imad H. Tahir – Senior consultant of internal medicine - clinical history taking. 2020 – 2021.
❑ Habits. Ask about: Tobacco smoking, alcohol consumption, drug
abuse, caffeine use.
*If the patient didn’t smoke cigarettes …….. say he/she is nonsmoker.
*If the patient was a cigarettes smoker and stop smoking .... Say he/she is
ex-smoker.
*If the patient is still smoking cigarettes …... Say he/she is smoker and
calculate the pack-year unit ( as a quantitative assessment of cigarettes
smoking).
𝐍𝐨. 𝐨𝐟 𝐜𝐢𝐠𝐚𝐫𝐞𝐭𝐭𝐞𝐬 𝐬𝐦𝐨𝐤𝐞𝐝 𝐝𝐚𝐢𝐥𝐲 𝐛𝐲 𝐭𝐡𝐞 𝐩𝐞𝐫𝐬𝐨𝐧 𝐗 𝐍𝐨.𝐨𝐟 𝐲𝐞𝐚𝐫𝐬 𝐨𝐟 𝐬𝐦𝐨𝐤𝐢𝐧𝐠
Pack-year =
𝟐𝟎
#If the patient didn’t drink alcohol …... Say he/she is non-alcoholic.
#If the patient was drink alcohol and stopped it ……... Say he/she is ex-
alcoholic.
#If the patient is still drinking alcohol .... Say he/she is alcoholic and till
the amount that the patient drink daily in ounces.

Dr. Imad H. Tahir – Senior consultant of internal medicine - clinical history taking. 2020 – 2021.
Ask about:
➢ Menarche date (the first menstrual cycle).
➢ Menstrual cycle (regularity, amount of blood “menses”,
pain during the menstruation, cessation of the
menstruation “amenorrhea” ).
Menorrhagia (heavy menses).
Oligomenorrhea (little amount menses).
Dysmenorrhea (painful menstruation).
➢ Pregnancy / oral contraceptive pills (OCCP) use.

Dr. Imad H. Tahir – Senior consultant of internal medicine - clinical history taking. 2020 – 2021.