HISTORY TAKING IN IMED

History Components
• Bio Data/ Identifying Data
• Chief complaints
• History of presenting illness
• Past medical history
• Family history
• Social history*
• Review of systems
• Summary
 Bio Data/ Identifying Data
• Name
• Age
• Sex
• Marital status
• Significant known medical illness; RVD status
• Residence;
• Occupation
• Facility referred from as applicable
• Informant
 Chief Complaint(s)
• Brief statement of the problem and duration (get
a sense if acute/chronic)
• Listed in chronological order
Complaints +duration of each
• Example:
1. Cough 4/7
2. Hotness of body 3/7
3. Difficulty in breathing 2/7
 History of Presenting Illness (HPI)
Outline
Patient was well until/ The patient is a known X patient whose
condition was controlled and was stable until…when he/ she
presented with ( symptom) – for each
• Onset –when and how? Sudden or gradual
• Course- Progressive, stationary, regressive
• Each symptom (P/C)
– Quality / character (dry, wet, paroxysmal, persistent cough)
– Location
– Intensity
– Aggravating factors
– Alleviating factors
– Predisposing factors ( contact with pneumonia patient)
– Precipitating factors (causative – cold)
– Associated factors (when symptom occurs, is it accompanied by others or does it occur independently)
– Medication- Taken? how long and Effect
• Health seeking behaviour
 History of Presenting Illness (HPI)
• For chronic illnesses, name the illness, duration and compliance to
medication
• Answer four questions- what is the cause of the patient’s
admission?
• What disabilities did they have at admission?
• How have the disabilities changed in the course of admission?
• What are the possible cause ( rule out important negatives n
mention positives)
• Health seeking behavior?
 Past Medical History
ILLNESSES
1. Medical
• chronic illnesses and current treatment
– E.g. Asthma, Diabetes, Sickle cell disease, malignancy, jaundices, rheumatic
fever, high BP, heart disease, stroke, epilepsy, PUD, anesthetic problems
• Known allergies to food and medication
2. Hospitalizations in particular ICU –reason, date
3. Surgeries (operations)- procedure, complication, date
4. Accidents and Injuries
5. Blood transfusions
6. Treatments- drug history
1. Tablets or injections
2. Off-the –shelf or over the counter
3. Herbal remedies
4. The pill
5. Allergies to drugs
• Members of the family
Family History
– Parents/Guardians
• Name, age, consanguinity
• Marital relationship- married, come we stay
• Health condition
– Siblings
• Number, sex and ages
• Health condition
• Previous/current significant illnesses
• Medical problems in family, including
– the patient's disorder*;
– diabetes, seizures, asthma, allergies, cancer, cardiac, renal or GI disease,
tuberculosis, behavioural problems, mental illness,
• Deaths in the family
– Unexplained death eg sudden cardiac death
– Cause of death
– Age at death
– Closeness to patient
 Social History
• Level of education
• occupation and employment status
• Housing: number of rooms, windows, floor type, roof type, safety features; ease of sunlight
exposure, fuel used, Sleeping arrangements
– Water: source (distance from household); daily amount used; treatment and storage
– Sanitation: human waste disposal (type e.g. WC toilet, VIP latrine) & household waste
disposal; distance from water source, pets at home
– Immigrants- for how long have they been in the country
• Drug abuse- cigarette smoking ( pack-years), alcohol abuse( type and quantity per day for
how many years), recreational drug use
• Marital status, spouse (age, level education, occupation, health status), children( ages, health
status) genetic conditions in the family
• Nutritional History- Current diet ( ? Family diet – 24 hour recall)
• Quality of diet – is it balanced? – detail constituents
– Frequency ( 3 main meals and 2 snacks)
– Variation
• Appetite
• Change in feeding habits
• Food allergies
 Obs/ Gyn history
• Menstrual; age at menarche, premenstrual or postmenopausal,
frequency, amount, duration, spotting or clots, pain or cramps ,
number of pads per day
• STIs or UTIs
• Use of contraceptives ( family planning)
• Pap smear, mammogram, HPV vaccine
• Sexual history
– Coitarche, frequency, number of partners, use of contraceptives,
discomfort during coitus, bleeding during or after coitus.
• Parity, gravidity
• Number of abortions or miscarriages if any n when
• Number of children, dates born, ANC visits, Birth history,
Complications during pregnancy, during and after delivery
 Review of Systems
• General/constitutional: Overall health, weight loss, fever, fatigue,malaise, lethargy, growth
pattern, itch rash
• HEAD; injuries, hair loss, headaches, scalp infections
• Skin: Rashes, bruising, lumps/bumps, nail/hair changes, color, texture
• Eyes: Visual problems, eye pain, visual acuity, use of glasses, abnormal tearing or injuries, prior
surgery
• Ear, nose, throat: Frequency of colds,sore throat, sneezing, stuffy nose, discharge, mouth
breathing, snoring ,hearing,pharyngitis, otitis media, adenitis, sinusitis
• Teeth: permanent teeth, number of teeth at one year of age
• NS: vision, hearing, headache, nervousness, dizziness, tingling, seizures, convulsions, habit spasms,
tremor, ataxia, syncope, hyperactivity
• RS:recurrent Cough, shortness of breath, wheezing, respiratory distress, chest pain, frequency of
Upper RI, pneumonia, TB, exposure to TB patient, chest radiograph
 CONT.
• Cardiovascular: Chest pain, exertional dyspnea, CHF, murmurs, syncope, excessive
sweating around scalp, palpitations, cyanosis, pedal- presacral edema, blood
disorders, rheumatic fever
• Gastrointestinal: Nausea/vomiting, spitting up, diarrhea, recurrent abdominal
pain, constipation, blood in stools. Encopresis( incontinence), jaundice, discomfort,
appetite, problems with food, weight changes, rectal bleeding
• Genitourinary: Enuresis, Dysuria, hematuria, frequency- polyuria, stream
character, vaginal discharge, menstrual history,bladder control, penis or testis
abnormalities.
• Musculoskeletal: Weakness, muscle or joint pain, gait abnormalities,postural
deformities, scoliosis, exercise tolerance, paralysis. Movement limitations, swelling
• Endocrine: Growth delay, polyphagia, excessive thirst/fluid intake, menarche,
polyphagia, goiter, thyroid disease,time-pattern of pubescence, hyperactivity
• Rheumatologic: limp, joint swelling, hairloss, skin rash, dry mouth, mouth ulcers,
dry or sore eyes, cold extremities
 Summary
• Summarize the history in one sentence:-
– Name and age
– Chief complaints
– Key HPI elements and
– Other significant components of the history
 GENERAL EXAM- COMPONENTS
1. General condition of the patient on
observation
2. Nutritional status
3. Any interventions
4. Vital signs- BP, HR, Temp, RR…giving correct
units
5. Discrete signs