Taking a History
1) Introduce yourself to the patient and establish their name and age
2) Ask an open-ended question to record ask their presenting
complaint?
• E.g. what is your problem today?
• Let them finish their initial statement uninterrupted
3) Explore the presenting complaint
• How long has it been going on?
• Where is it?
• How has it progressed?
• Is there any thing else that’s associated with it?
• Did it come on suddenly or gradually (over how long)?
• What makes it better or worse?
• How bad is it (1-10)?
4) Explore risk factors for the presenting complaint
• E.g. Do they have TB contact, hypertension or diabetes
5) Past medical history
• Any other problems
• Ask specifically about HIV status (need to know about how long on
ARVs, whether on CPT, any CD4 counts?)
6) Medications
• What are they taking including local remedies/ non-prescribed
medications?
7) Any allergies
8) Social and Family history
• Who else is at home?
• What is there job?
9) How healthy are they usually?
• E.g. have they been house bound for years?
10) Alcohol, Tobacco, Other drugs, any local treatments
11) Anything else they wish to add?
Provided by T. Whitfield 2012
Specific History taking
Respiratory History and guide
Cough
How long has the patient been coughing?
What are they coughing up?
What colour is the sputum?
Is there any blood?
Is there fever?
Night sweats weight loss
HIV status?
Shortness of breath
How long have they been short of breath?
What makes it better what makes it worse?
Are they short of breath lying flat?
Are they more short of breath when walking?
Any chest pain/ cough?
Any swelling of the abdomen/ ankles?
Wheeze
Are they known to have asthma?
How long have they been wheezing?
Any known triggers? Animals/dust
Any known allergies/ hay fever?
Features of common respiratory illnesses
Pneumonia:
cough comes on over a day or so, cough up yellow, green phlemn or nonproductive. Rarely blood and only after prolonged coughing. Fever usually
present. Tend to become very short of breath quickly.
TB:
Over 3/52 cough. Productive with soutum often bloody. Weight loss fever and
night sweats. Often HIV positive.
Pneumocystis jirovercii pneumonia (formally PCP):
Non-productive cough, weight loss, fever, short of breath on exertion. HIV
positive (need to be imunosupressed CD4 <150 cells/mm3)
Heart failure
Cough with pink frothy phlemn or non productive. Worse shortness of breath
on lying flat (orthopnoea), they need more pillows at night to keep propped up,
worse shortness of breath on exertion. Can have chest pain on exertion.
Ankles often swell. May be a wheeze.
Provided by T. Whitfield 2012
Asthma
Wheeze the predominant feature, usually begins in childhood, may be a
cough with haemoptysis. Often allergies/ hay fever also present. Asthma is
usually relieved by salbutamol inhaler/neb.
Neurological history
Weakness
how quckly did it come on?
What is the distribution?
Any pain?
Any sensory disturbance?
Any recent injury?
How is the speech?
How is the swallow?
Headache
Where is the headache?
Is it constant?
How did it come on?
Any neck pain?
Any GCS disturbance?
Any associated neurological symptoms (weakness/ numbness)?
Any visual disturbance flashing lights, dizziness?
Fitting
How many fits in the last 24 hours?
Are they waking up between fits?
Have they had any previous fits?
Are they on medications?
Any complaint of headache other neuro-symptoms?
Have they lost continence?
Interpreting Neurological History
Stroke:
Symptoms come on quickly (within 30 minutes), effects one side and not the
other.
It may effect the face, disturb speech and swallowing. Sensory symptoms will
be on the same side and ‘negative’ (not able to feel or reduced sensation).
Haemorrhagic strokes are usually very painful whilst ischaemic strokes are
usually painless. Haemorrhagic strokes are more likely to reduce the GCS
and induce a seizure.
Spinal chord compression
Compression of the chord usually causes sudden onset of loss of power and
sensation bilaterally below a certain level. The level is defined by the sight of
the lesion in the spine.
Provided by T. Whitfield 2012
There may be back pain due to the spinal damage. Patient will lose sensation
of their genitals, become incontinent of bladder/ bowels or suffer retention of
urine. May have TB symptoms. Other common causes schistosomiasis and
trauma.
Subarachnoid haemorrhage
Very classical history of sudden onset back of the head headache-‘ worst ever
had.’ Like being hit on the head. May lose consiousness/ be confused.
Epilpesy
Everyone is susceptible to having a fit, primary epilepsy itself is a low seizure
threshold and has usually been established in childhood. In adults a new
onset of seizure is often secondary to some other pathology Seizures occur in
acutely ill patients especially those with malaria, sepsis and hypoglycaemia if
the seizures resolve with the illness they could be explained. Intracranial
space occupying lesions (SOL) are common causes of new onset fits in adults
they are associated with headache. SOL can cause slowly progressive
headache and focal neurological signs. Toxoplasma, cryptococcoma and
tuberculomas are SOL’s and more common in patients with HIV. CT/MRI scan
is the ideal tool for initial assessment.
Abdominal symptoms
Abdo pain
Where is the pain?
Does it come and go?
What makes it better/worse?
Can they eat or drink?
Does food make it better or worse?
Diarrhoea
How many episodes in the past 24 hours?
What colour?
Any blood?
Any melaena? (Black tarry stools very foul smelling)
How much fluid have they taken in?
Vomiting
How many episodes in the past 24 hours?
What colour?
Any blood?
How much fluid/food have they taken in?
How are the bowels and bladder?
Any flatus passed?
Dysphagia
What happens when you swallow?
Does the food get stuck?
Can you swallow solids or liquids more easily?
Do you cough after trying to swallow?
Provided by T. Whitfield 2012
Is it painful to swallow?
Weight loss
How much weight over how long?
Is there an obvious cause? (diarrhoea, starvation, diagnosed illness)
Any problems eating or drinking?
Any problems with the bladder or bowels? (Any blood in the stool?)
Any fever, night sweats, cough, TB contact?
HIV status?
Do they feel tired?
Urine output
Any obvious fluid loss(diarrhoea, burns, bleeding, fever)?
What is the fluid intake?
Any dysuria?
What colour is the urine?
Any blood in the urine?
Any shortness of breath?
Any loin pain?
Any fever?
Jaundice
How long have you been yellow?
Has it come on suddenly?
How long have you been itching?
How much alcohol do you take?
Do you know your hep B status?
Do you take any tablets? (esp. TB meds and traditional remedies)
Any light greasy stools?
Any dark urine?
Any abdominal swelling?
Any abdominal pain?
Have the guardians noticed any confusion?
Interpreting the abdominal history
Viral diarrhea and bacterial diarrhea occur and resolve quickly. Blood in the
diarrhea is dysentery and warrants antibiotic treatment. White diarrhea is
cholera and necessitates urgent treatment and isolation.
Black tarry stools suggest blood loss from the stomach or duodenal area,
greasy stools suggest either pancreatic insufficiency or malabsorption from
something such as Guardia.
Prolonged weight loss and diarrhea suggests different causes such as
amoebic dysentery and HIV.
When taking a history of vomiting you must distinguish between acute
gastroenteritis and obstruction of the GI tract. If the tract is obstructed the
patient may vomit faeces and will not pass wind or stool. There may also be
some abdominal swelling.
Provided by T. Whitfield 2012
Burning and stinging of the urine suggests infection, poor urine output may be
due to poor intake or fluid losses from the bowel or blood loss.
Jaundice will come on quickly of newly infected with a virus such as Hep A,
Hep B or EBV, if colicky pain is present then gall stones are more likely. If
there is greasy pale stools and dark urine this suggests obstructive jaundice
and could be due to gall stones or pancreatic tumour (painless). A USS
abdomen should show dilated billary ducts to differentiate between intra and
post hepatic jaundice. Fulminant hepatic failure will lead to encephalopathy
and confusion. Alcohol and hepatitis are common causes of liver failure as are
TB meds.
Dysphagia is either mechanical or neurological. If it is mechanical it is caused
by a blockage, foods will tend to stick in the throat. Pain can be caused by
oesophageal candidiasis which is common in HIV patients. Neurological
problems mean the swallow is not coordinated properly, caused by things
such as stroke, these patients struggle with fluids and tend to aspirate.
Chest pain
What type of pain is it?(burning, stabbing, crushing)
Does it go anywhere?
How long does it last?
Anything bring it on?
Any tenderness?
Chest pain history
Heart attacks and angina
Cardiac pain tends to be central and may radiate to the left arm. It will usually
be present with shortness of breath. People with cardiac pain will be unable to
exercise normally. In angina the pain is brought on each time the patient
exercises and this pain is then relieved by rest. As time progresses the patient
will be able to manage less and less exercise.
During a heart attack the patient’s most classically describe crushing chest
pain in the center of the chest. This usually lasts around 30 mins and rarely
more than an hour. The patient feels short of breath, hot and sweaty.
Occasionally diabetics, the elderly and frail have ‘silent’ heart attacks where
they do not feel as much pain due to nerve damage. The diagnosis is made
through ECG findings and cardiac enzymes (if available).
Pulmonary embolism
This presents with sudden onset sharp pain which is worse in inspiration. The
pain will persist until the clot resolves. The patient is short of breath and will
have difficulty walking. The pain is classically situated at the side of the chest
and not in the center, but this is not always the case and depends on where
Provided by T. Whitfield 2012
the clot has lodged. Larger emboli can cause very severe illness and be fatal.
Clots often come from the legs and often one leg will be swollen. There may
be a history of inactivity (eg. long bus ride), contraceptive pill, trauma or
surgery.
Heart burn
This pain is central and usually does not radiate. The pain is burning in nature
and may be alleviated by taking meals. Oesophagitis will lead to pain during
swallowing (though look carefully for thrush and HIV which are common
causes of dysphagia).
This pain can be constant throughout the day but does not stop walking or
cause any significant shortness of breath.
Fever
How often is the fever? (every day, every night)
How long has it been going on for?
Do you have any joint aching?
Do you have any pain anywhere?
Fever History
Fever can occur in numerous illnesses. Fever coming on in a day to a week
tends to be bacterial, viral or malarial. Longer onset fevers tend to reflect
chronic conditions such as TB, HIV or malignancies. This needs to be fit in
with other signs.
Provided by T. Whitfield 2012