History taking

What is History taking?

It is a process by which information is gained by a physician
by asking specific questions to the patient with the aim of
obtaining information useful in formulating a diagnosis and
providing medical care to the patient
Importance of History Taking?
Obtaining an accurate history is the critical first step in
determining the etiology of a patient's illness.
Diagnosis in medicine is based on
Clinical history
Physical Examination
 Investigations
A large percentage of the time (70%), you will actually be able
make a diagnosis based on the history alone.
How to take a history ?
“Always listen to the patient they might be telling you the
diagnosis” . (Sir William Osler 1849 - 1919) The basis of a
true history is good communication between doctor and
patient. It takes practice, patience, understanding and
concentration.
Always listen to the patient they might be telling you
the diagnosis” . (Sir William Osler 1849 - 1919)
A large percentage of the time (70%), you will
actually be able make a diagnosis based on the history
alone.
How to take a history ?
 “Always listen to the patient they might be telling you the
diagnosis” . (Sir William Osler 1849 - 1919)
The basis of a true history is good communication between
doctor and patient.
It takes practice, patience, understanding and concentration.
“Always listen to the patient they might be
telling you the diagnosis” . (Sir William
Osler 1849 - 1919)
Approach to history taking

Your look is important

 Your dressing
Good look and dressing
Bad dressing and poor look
Introduce your self and create a rapport
If it is culturally appropriate
Be alert and pay full attention like this (Good
attention)
Good attention
Poor attention
Poor attention
Approach to history taking
Ensure consent has been gained.
Maintain privacy and dignity.
Ensure the patient is as comfortable as possible
Summarize each stage of the history taking process.
Involve the patient in the history taking process
“If in a bad mood or distracted during the
consultation, you can end up making a
history rather than taking a history”.
Components of History taking
Patient’s profile
Chief complaint
History of the present illness
Past medical history
Family history
Socioeconomic history
 System Review
Patients profile
Date and Time Name Age Sex
 Religion Marital status Occupation
Address Who gave the history?
Chief complaint
The main reason for which the patient is trying to seek
medical help by visiting the physician.
Usually a single symptoms, occasionally more than one
complaints eg: fever, headache, pain, etc
The patient describe the problem in their own words.
It should be recorded in patients own words.
The complain should be recorded with their onset duration
How to ask for chief complaint?
What brings your here?
How can I help you?
What seems to be the problem?
If there is more than one complaint, it should be written
according to chronological order
Example
Example,
Fever-2 weeks,
Productive cough-1 week,
Vomiting
 -2 days,
Fatigue-1day,
History of the present illness
Elaborate on the chief complaint in detail
Ask relevant associated symptoms
Gain as much information you can about the specific
complaint.
Lead the conversation by asking questions.
Always start with an open ended question and take the time
to listen to the patient’s ‘story’.
Once the patient has completed their narrative then closed
questions can be asked to clarify .
Leading question are to be avoided.
Open questions allow patients to express their own thoughts
and feelings, e.g. 'Is there anything else that you want to
mention?’
Closed questions are requests for factual information, e.g.
'When did this pain start?’
Leading questions are based on your own assumptions that
lead the patient to the answer you want to hear.
In details of present problem with- time of onset/ mode of evolution/
any investigation ; treatment &outcome/any associated +’ve or -’ve
symptoms.
Avoid medical terminology and make use of a descriptive language
that is familiar to patients
Sequential presentation
Always relay story in days before admission
Narrate in details
HPI {Tips to gather information }
Site
Onset
Character
Radiation (of pain or discomfort)
Alleviating factors
Timing
Exacerbating factors
Severity
S
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EXAMPLE OF HPI
The patient was apparently well 1 week before the admission
when the patient fell while gardening and cut his foot with a
stone.
By that evening, the foot became swollen and patient was
unable to walk. Next day patient attended a private clinic
where they gave him some oral medicines.
The patient doesn’t know the name of the medicines given
but says that he was told the medicine would suppress his leg
pains .
however There was no improvement in his condition.
Two days prior to admission in ward , the swelling in the
foot started to discharge pus. There is high fever and rigors
with nausea and vomiting.
Past medical history
Any history of similar complaint in the past
Other medical problems the patient has or had
Any chronic disease present like hypertension, diabetes etc
Past hospitalizations and past surgeries
Medications if any taken in the past (dosage and duration)
Allergies
 Pediatric: Birth history, Developmental Milestones,
Immunizations
 Gyane /Obstetric history if female
Family history
It is important to establish whether there are any genetically
transmitted diseases within families
Any illness run in the family?
Similar history in the family, Parents and siblings suffering
with any chronic illness
Parents if died, how old and what they died of
You should be able to collect relevant family history
depending upon the present illness.
Example, Patient has come due anemia , Try to rule out
sickle cell, thalassemia / G6PD deficiency
Socioeconomic history
Smoking history - amount, duration and type.
Drinking history - amount, duration and type
Any drug addiction
Sexual history if suspected STI
Occupation, social and education background, financial
situation
System Review
General
Weakness
Fatigue
Anorexia
Change of weight
Fever
Lumps
Night sweats
Gastrointestinal/Alimentary
Appetite (anorexia/weight change)
Diet
Nausea/vomiting
Regurgitation/heart burn/flatulence
Difficulty in swallowing
Abdominal pain/distension
Change of bowel habit
Haematemesis , melaena
Jaundice
Cardiovascular
Chest pain
Paroxysmal Nocturnal Dyspnoea
Orthopnoea
Short Of Breath
Cough/sputum
Palpitations
Cyanosis
Respiratory System
Cough(productive/dry)
Sputum (colour, amount, smell)
Haemoptysis
Chest pain
SOB/Dyspnoea
Tachypnea
Hoarseness
Wheezing
System review
Urinary System
Frequency
Dysuria
Urgency
Hesitancy
Terminal dribbling
Nocturia
Back/loin pain
Incontinence
Character of urine: color/ amount (polyuria) & timing
Fever
Genital system
Pain/ discomfort/ itching
Discharge
Unusual bleeding
Nervous System
Visual/Smell/Taste/Hearing/
Speech
Head ache
Fits/Faints/Black outs/loss of consciousness(LOC )
Muscle weakness/ numbness/
paralysis
Abnormal sensation
Change of behavior or psyche
Musculoskeletal System
Pain – muscle, bone, joint
Swelling
Weakness/movement
Deformities
Now you’ve got your information
Give a Summary
 Ask if you’ve understood the information correctly
Ask if there is any other information that the patient wants
you to know
 Advise what your plan would be
Check with the patient that they are in agreement with your
plan