SKILL 1 HISTORY TAKING SKILLS

Structure

1.0 Objectives
1.1 Introduction
1.2 History Taking
1.2.1 Purposes of History Taking

1.2.2 Stages of History Taking

1.3 Sources and Techniques of Information

1.4 Collection of Information
1.5 Reporting and Recording
1.6 Format for History Taking
1.7 Sample Format of History Taking
1.8 Let Us Sum Up
1.9 Key Words
1.10 Activities
1.11 References

1.0 OBJECTIVES
After studying this practical, you will be able to:

• explain the various techniques of history taking;

• collect and record information as per guideline.

1.1 INTRODUCTION
You have learnt in theory course about various important lessons on Home Based
Care. In this skill you will be learning the most important areas of assessment
which will provide information about the patient's health profile i.e. the history of
the patient. History taking is the first contact with the patient. The areas on which
you need to collect the history of patient are identification data, present complaints
of the patient and past medical history, family history, personal & social history
etc.

1.2 HISTORY TAKING

History taking is an art of gathering information to identify or to detect the problems
of patients. It is a systematic, step by step process of collecting information by
asking questions (interview), making head to toe observation and physical
examination. Let us learn the important aspects of history taking one by one. 5
Practical Manual- I 1.2.1 Purposes of History Taking

The purposes of history taking are to:

• introduce each other

• establish good interpersonal relationship

• obtain the information required for contacting himlher if the need arises.

• allow the patient to describe his/her own problems and expectations.

• identify the patient's feelings about his symptoms, e.g., the patient may show
fear, guilt, self protective in his first statement.

• identify any change in the patient's normal pattern of living that mayor may
not be due to illness.

• collect and record information that may be helpful in making diagnosis and
caring for the patient/client

Fig.1.1: Proper identification is needed to provide patient care

1.2.2 The Stages of History Taking

History of the patient is an account of the illness and is usually the most important
part of assessment. There are three main stages. The first stage is the introductory
phase, the second is the principal phase i.e. the story of current illness, and third
stage is the interrogation phase.

Stage - 1 The Introductory Phase

In this stage you should greet and introduce yourself in a friendly way and remember
6 your patient's name. An introductory chat about personal matters in general will
help the patient to adjust with the stranger. For example, conversation about the History Taking Skills
patient, patient's family etc. can often initiate good rapport. It is important for you
to observe the patient's appearance, and the environment and appreciate where
and when required.

Stage - 2 The patient's account of the current illness (Principal stage)

Once you have introduced yourself and know the patient's name you should then
try to enquire about the problems, you listen to these problems carefully, make
your own observations accordingly, give positive response and assure help and
guidance. This will help to establish good relationship and also in getting the
information. Sometimes information is suppressed involuntarily because of anxiety
or fear of disease such as cancer. In such cases listening will lessen the anxiety.
Some patients are unable to give a history because they are too acutely ill or
unconscious. In such situation, information should be obtained as much as possible
from any of the family members (caregiver).

Stage - 3 Interrogation

When the patient has completed his account of the current illness, the next step
is to clarify the description by specific questioning to know about the illness from
the first symptom to the date of interview. Questions should be put in such a way
so as to encourage the patient to tell hislher own illness/problems. Questions
should be simple. Once the patient's history has been expanded by you, enquiry
should then be made about other symptoms, drugs, allergies, previous illness and
about the family and social background.

Activity -1 Some one in your family/neighborhood has fallen sick. You talk
to the person keeping in mind stages of history taking and collect past,
present history of illness. Refer history taking format.

1.3 SOURCES AND TECHNIQUES OF

INFORMATION·
The patient's problem may be physical, emotional or social but each one would
affect the patient as a whole. Information need to be collected by asking the
patient to report about hislher problems, by doing head to toe examination,
observation and going through records and lab reports. There are two ways to
collect information: .

• Subjective information - From the patient by asking questions, like how are
you? what are your problems?

• Objective information - Going through records and reports, e.g. noting the
temperature, pulse and respiration rate, urine report, blood report.

Technique of information - How to collect the information:

The subjective and objective information can be collected by the following three
techniques: 7
Practical Manual- I • Interview,

• Observation,

• Examination

A) Interview

You might be familiar with the term interview. There are two persons who talk to
each other and share information. The purpose of the interview is to encourage
an interchange of information between the patient and you (home care provider).

The basic techniques of interview

• Conduct interview in a quite place, see that patient is comfortable and provide
pnvacy.

• Greet the patient. Introduce each other by asking name and other relevant
information.

• Observe the environment, patient condition. Take necessary actions according

to the situation. This will help in developing confidence and good interpersonal
relationship.

• Ask the patient if he/she requires any help. Some patients will say 'No' to
your offer of help. Usually, their fear is so great that they are confused. Simple
conversation works best in gaining confidence even if the patient says 'No'
to you.

• Be sure that facial expressions, body movement and tone of voice are pleasant,
unhurried so that they convey the attitude of a sensitive listener and the patient
also feels free to express his thoughts and feelings.

• Re-assure the patient with caution.

• Guide the interview so that the necessary information is obtained.

B) Observation

Observation includes:

• Head-to-toe observation in general, to identify any abnormality.

• Checking vital signs i.e. TPR and B.P.

C) Examination

The physical examination is with regard to the major systems of the body. These
are skin, head, eyes, ears, nose, teeth, mouth and tongue, throat, neck, respiratory
system, circulatory system, gastrointestinal system, urinary system, nervous system
etc. Physical examination is done by a doctor, This is important for you, because
when doctor is examining the patient, you can assist him/her.
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The purpose of the physical examination is to observe any findings not reported History Taking Skills
in the history. It helps to obtain objective information about the individual's health
state.

Sources of information:

• Patient's relatives

• Observations by you

• Health records

• Laboratory results

Activity 2 - Interview five patients in your locality and collect subjective and
objective information and make summary so that it can be recorded for
future use.

1.4 COLLECTION OF INFORMATION

Identification data refer to the information about the person and his/her personal
aspects.

Chief Complaint: It is the expression of the patient of his/her current problems.

Data is obtained directly from the patient. Sometimes patient may not be able to
express his problems. In that case relative should be contacted to get the information
to have the complete history.

A) History of Present illness

History of present illness is mainly referred to as signs and symptoms presented

by the patient in the present episode for which s/he is getting treatment. So
detailed account of the present illness should be taken on the following aspects:
e.g., When are symptoms first noticed?

• Are the changes in the patient sudden or gradual i.e., onset is acute or
insidious?

• Is there any change in patient's attitude, interest, habit, and health status?
e.g., appetite increase or decrease,

• change in sleep pattern,

• change in maintaining personal hygiene,

• change in level of consciousness,

• general behaviour of the individual like agitated, anxious, memory

impairment?

B) Past History of illness

In medical illness you should collect the history on the following aspects:

• Has the patient suffered any medical problems earlier like diabetes mellitus, fever, 9
hypertension?
Practical Manual- I • Was the patient given any treatment at home or he/she was hospitalized and is
alright after the treatment?

• Was there any history of drug allergies?

• Was any surgical intervention/treatment required?

• Has the patient sufferedfrom any infectiousdiseases e.g.,measles,mumps, chicken

pox, or any other infectious problems.

If patient can't mention the drugs or has any doubt, it may be necessary to ask
the patient to produce pills for identification by matching them against a standard
chart. Medical information provides you the information whether patient is going
through any type of stress.

C) Family History

Who all are the members of family? Is it a nuclear or joint family? Is there any
history of physical or psychiatric illness in the family? Is there any use of alcohol
or drugs in the family. The causative factors of many diseases are frequently
inherited. The patient's early relationship with the parents and siblings are also
fundamental factors in the psychological assessment.

D) Personal History

It is also important to collect personal history from the patient. It includes prenatal
history, infancy, childhood, adolescence, adulthood and maturity. If the patient is
in early adulthood, then the history may be asked up to adulthood. Though it is
difficult to collect the history chronologically, but you must get the information you
desire to get.

E) Social History

An individual's reaction to his occupational and social environment may have

great impact on his health. Enquiries should be made about home, occupation,
leisure interests including physical recreation and habits of the use of alcohol and
tobacco.

1.5 REPORTING AND RECORDING

Definition: Reports are either written or verbal accounts of patient's condition
which are given from time to time to the patient or the family members or to the
attending physician. It helps to know the exact position of the patient.

General rules of reporting:

• It should be written neatly, no overwriting.

• Accuracy is necessary. e.g. be sure of the name of the patient.
• Use correct language and spelling.
10 • Date and time to be mentioned.
• Be specificin writing description,"Pain in the hand" is a vague statement, whereas History Taking Skills
"pain in the left upper arm" is definite and of value. At the end of the report put
your signature.

Fig.l.2: Recording of the History

Hence after completion of taking history of your patient, you need to report
verbally about the patient's condition to the relatives/informant, or write the
information you have collected using the history guideline format by following the
above rules so that proper line of communication can be maintained.

1.6 FORMAT FOR HISTORY TAKING

1) Identification Data:

Name
Age/Sex
Marital Status Married / Unmarried
No. of family members
Education Undergraduate/GraduatelPost Graduate
Occupation Working/Non Working
Address

Income
Religion

Any habits Alcoholic/Smoking

Dietary Habits Vegetarian/Non Vegetarian.
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Practical Manual- I Chief complaints of the patient

History of present illness

Duration of illness VVeeks _

Months _

YeMs _

Past history of illness

• Major illnesses if any - heart diseaselblood SUgM.

• Injuries if any such as fracture, paralysis, surgery/amputation.

• Medicine taken in the past

Side effects -r--v- _

Allergies _

Any infectious disease _

Family History of any disease :

Social History:

• Interaction with family, friends and relations/neighbours. YeslNo

• Visiting the temple for prayers YeslNo

• Any other social get together YeslNo

• Any other social interests _

• Religion, whether practicing or not, culture, beliefs and taboos.

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Recreational Activity: History Taking Skills

• Usual recreational activities such as reading, writing, listening music.

• Problems with ambulation YeslNo

• Fatigue YeslNo

Comfort, rest, sleep:

• Usual sleep patterns Regular/Irregular

• Any help required to promote sleep YeslNo

• If yes (specify) _

• Presence of pain or discomfort while sleep YeslNo

Nutrition:

• Foods generally avoided _

• Likes, dislikes _

• Vitamin or mineral supplements taken

• Problems with eating, tastes or smell

• Dentures _

• Recent changes in food-fluid intakes

• Initial weight _____ Changes in weight (recent, long-term).

Elimination:

• Problems with urination

• Bowel probl'ems

Constipation YeslNo

Diarrhoea YeslNo

Incontinence YeslNo

Perception and coping:

• Present concerns related to health or life events Yes/No

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Practical Manual- I • Expected changes in life-style because of present health problem Yes/No

• Recent changes in feelings about self or body image Yes/No

• If yes, specify _

• Spiritual practices or beliefs found helpful at present Yes/No

• Availability of significant others as supportive persons Yes/No

Signature of history taker

1.7 SAMPLE FORMAT OF TAKING HISTORY

Chief Complaint .

"I am a 73 years old man. I feel very much tired almost throughout the day and
unable to move out independently without other's help. Even if I try, an
apprehension appears that I may fall down. In such an event, I may suffer physical
injury, consequent to which there will be more misfortune to myself. I am a lonely
person. My wife died about six months back. My son and the daughter-in-law
are employed persons. They need to attend their respective work. There is none
to offer me help. The loss of my wife, who used to give me all the support as
need be, has caused a great vacuum in my life. Who would help me? None! Who
will take care of me? None! "

The patient's history in brief:

Mr, X is a 73 years old male and belongs to a middle socio-economic background.

He lives in a family consisting of his only son, daughter-in-law, two grand children
aged 7 &10 years of age respectively. On the first encounter with him, he reported
with the.following complaints:

• Pain all over the body.

• Giddiness
,
• Respirationdifficulty
• Sleep disturbance
• Having problems in vision

He feels insecure to maintain the daily activity due to his apprehensions that he
may fall down. He has no personal vigil to care for himself. Consequent to such
developments, he has lost interest to take food also.

History of Present lllness

Mr. X was apparently well for the last three months. But, subsequently, thereafter,
he developed all such ailments. These occurred after he lost his spouse six months
14 back (this was revealed by Mr. X's son and daughter-in-law). The patient has
been taken to the doctor and was given some symptomatic treatment. The attending History Taking Skills
physician also advised to undergo an eye surgery. But, the eye surgery could not
immediately be taken up as the cataract in the left eye was an immature one. His
wife was the significant person in his life and he lost her 6 months ago. He has
lost interest in life and feeling insecure and unable to maintain the daily needs as
both the son and the daughter-in-law goes out for work. He feels lonely and
depressed sometimes.

The Past Medical History

Except for the minor ailments (related to the eye problem), he did not repeat any
major health problems.

Drug History

This cannot be presently elicited as there is no document like medical prescription

etc. However, the patient used to take vitamins and supplement any minerals now
and then.

Personal History

Mr. X is a retired government employee and drawing his retirement benefits like
the pension. Before that he used to maintain a smooth life with his job done
satisfactorily. In his marital life he used to maintain very good relationships with
his spouse, children and other members of his family. Presently, he is suffering
from disturbance of sleep and has lost his interest in taking food.

Social History

The patient, e.g., Mr. X lives in his own house. The house has all the requisite
facilities needed for a good living. Mr. X has friends and relatives who visit him
occasionally.

Economic Condition

With the pension he draws per month as a retired person he maintains himself
well.

On Examination:

General inspection State of health appears a thin built and looks

dehydrated. Not very well groomed, beard not
shaved and unstable gait.

State of Awareness Conscious, speech and language understandable.

Other Examination:

Temperature 36.5 Degree

Pulse 88/rninlRegular
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Practical Manual- I Respiration 32/m & wheezing sound heard

B.P. 150/90 mm. Hg.

Height and Weight Normal as per his built.

Eyes Looks normal with a spot in the left eye.

Ears Clean or dirty with wax.

Hair and scalp Loss of hair and dandruff found.

Mouth No impairment of teeth, foul smell (odor)

Summary: Mr. X who is a 70 years old man having a good family background
presently having an increase of B.P 150/90mmHg, a wheezing respiration, and
difficulty in his eye sight for which he neglects himself.

Emotionally he is being disturbed because of the death of his wife and feels lonely
as no one stays at home by virtue of their occupation and because of this he has
no interest in taking food.

1.8 LET US SUM UP

In this skill an attempt has been made to introduce you to the key features of
hjistory taking. The patient's history is a very important aspect of assessment. It
gives a full health profile of the patient's chief complaints, history of present, past
illness, personal and family history and psycho-social history. A guideline has been
provided for your ready reference to learn the skill of history taking. Rules for
reporting and recording document are also mentioned at the end of the unit.

1.9 KEY WORDS

Ailment Any minor disorder of the body.

Ambulation Having the capacity to walk.

Deteriorating Worsening.

Dyspnoea Difficulty in breathing.

Fatigue A condition of-being very tired.

Fluctuating Move up and down.

Gait Manner of walking.

Giddiness Feeling of turning round.

Objective Information When patient is examined by going through records

and lab reports.
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Problem It is a condition or situation that a patient cannot History Taking Skills
readily handle himlherself.

Subjective Information When information is received by the patient,

relatives or any others, neighbors.

Significant Important.

1.10 ACTIVITIES
Activity 1 Interview two patients in your locality and collect subjective and
objecti ve information and summarise it in diary.

Activity 2 Select two parients and take their history. Record as per the
format keeping in mind general rules as per guideliness.

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