Principles of History Taking
Dr Thamer Bin Traiki
Prepare yourself to be a good physician
History Taking
A process of gathering information during
patient interview as part of patient clinical
assessment.
Importance
• Obtaining an accurate Hx is the critical 1st step
in determining the etiology of a patient’s
problem .
• A proper history and examination will get you
to your diagnosis almost 70% of the time .
Set Up
– Your appearance is important (wearing proper uniform, ie.
Lab coats, I.D., etc.)
– Your way of asking the Qs
– See him walking in and not in the cubicle & allow
a relative to be there if the patient wants.
– Provide a safe & private environment
Cont..
• Introduce yourself
• Greeting patient
– By name
– Shake hands
– Avoid unfamiliar or demeaning terms
Be alert and pay him full attention
The way of getting the Hx
•
•
•
•
Ask open questions
Listen carefully
Take notes
Avoid interruption except
– Special situations
• History should be in the following order :
–
–
–
–
–
–
–
Personal data
Present complaint (c/o).
History of present complaint.
Systemic enquiry.
Past history: surgical, medical , drug history
Family history
Social history
Personal Data
Date and Time
Name & File number ( Medical record number)
Age
Gender
Religion
Marital status
Occupation
Residency
Who gave the history?
Chief Complaint
• Present complaint or problems :
– Symptom/Symptoms that caused patient to seek
care and their duration .
– In the patient’s own words
– If multiple , list them in order of severity .
Chief complaint may be misleading
Problem may be more serious than the chief
complaint
History of the presenting Illness
• Elaborate the symptom in medical terminology
– Provides full clear, chronological details of the history
of the main problem/s .
• Previous similar attack/s should be included
here .
• What had been done for the patient if any
• Elaborate the system involved.
• Add any related symptoms .
Systemic Review
• Negative symptoms are as important as
positive one.
• You have to ask about them all, and keep
repeating them in each patient, to
memorize them well.
Neuro
•
•
•
•
•
•
•
Nervousness
Excitability
Tremor
Fainting attacks
Blackout
Loss of consciousness
Changes of smell, Vision
or hearing
•
•
•
•
•
•
•
Muscle weakness
Paralysis
Sensory disturbances
Paraesthesiae
Headaches
Change of behavior
Fits
Cardiovascular & Resp
•
•
•
•
•
•
•
•
Cough
Sputum
Haemoptysis
Dyspnoea
Hoarseness
Wheezing
Chest pain
Paroxysmal nocturnal
dyspnoea
•
•
•
•
•
•
•
Orthopnea
Palpations
Dizziness
Ankle swelling
Pain in limbs
Walking distance
Temperature and color
of hands and feet
GI
•
•
•
•
•
•
•
•
Appetite
Diet
Abnormal Taste
Dysphagia
Odynophagia
Regurgitation
Indigestion
Itching
•
•
•
•
•
•
•
•
Vomiting
Haematemses
Abdominal pain
Abdominal Distension
Bowel habit
Melena
PR bleeding
Jaundice
Urogenital
• Loin pain
• Symptoms of uremia
–
–
–
–
–
–
Headache
Drowsiness
Fits
Visual disturbances
Vomiting
Edema of ankles, hands
of face
• Lower urinary tract
symptoms ( LUTS)
• Painful micturition
• Polyuria
• Color of urine
• Hematuria
• Male Infertility history
• Sexual history
Musculoskeletal
•
•
•
•
•
Aches or Pain in muscles, bones and joints
Swelling of joints
Limitation of joints movements
Weakness
Disturbance of gait
• Constitutional symptoms:
– Weight loss/gain
– Fever
– Night sweats
Past Hx.
•
•
•
•
•
•
•
Childhood illnesses
Adult illnesses
Accidents and injuries
Surgeries or hospitalizations
Blood transfusion
Drugs : Insulin, Steroids and OCP
Allergy to any medications or food
Family Hx
• Health of immediate family
– father , mother , 1st degree relatives
– HTN, DM , heart disease, contagious illnesses
• Potential for hereditary diseases
Social Hx
•
•
•
•
•
•
•
•
Detailed marital status
Living accommodation
Occupation
Travel abroad
Leisure activity
Smoking
Drinking
Eating habits
Sensitive Topics
• Alcohol or drug use
• Physical abuse or violence
• Sexual issues
Sensitive Topics Guidelines
•
•
•
•
•
•
Respect patient privacy
Be direct and firm
Avoid confrontation
Be nonjudgmental
Use appropriate language
Document carefully
– Use patient’s words when possible
Special Challenge
• Silence
• Overly talkative patients
• Patients with multiple
symptoms
• Anxious patients
• Limited intelligence
• Crying
•
•
•
•
Anger and hostility
Intoxication
Depression
Confusing behavior or
histories
• Developmental
disabilities
• Language barrier
Cont..
• False reassurance
– May be tempting
– Avoid early reassurance or “over reassurance”
• Unless it can be provided with confidence
Common surgical symptoms
• Pain
• Lump
• Ulcer
Pain Hx
1. Site
2. Time & mode of onset
3. Duration
4. Severity
5. Nature ( Character)
6. Progression of pain
7. The end of pain
8. Relieving factors
9. Exaggerating (Exacerbating) factors
10. Radiation
11. Cause
Visceral pain
• Visceral peritoneum is innervated bilaterally by the
autonomic nervous system.
• The bilateral innervation causes visceral pain to be midline,
vague, deep, dull, and poorly localized.
• Visceral pain is triggered by inflammation, ischemia, and
geometric changes such as distention, traction, and pressure.
( usually the result of distention of a hollow viscus ).
• Embryologic origin of the affected organ determines
the location of visceral pain in the abdominal
midline.
– Foregut(stomach to the second portion of the duodenum, liver and biliary
tract, pancreas, spleen) , present as epigastric pain.
– Midgut (second portion of the duodenum to the proximal two thirds of the
transverse colon) pain present as periumbilical pain.
– Hindgut (distal transverse colon to the anal verge) pain present with
suprapubic pain.
Parietal pain
• Parietal peritoneum is innervated unilaterally via the spinal
somatic nerves that also supply the abdominal wall.
• Unilateral innervation causes parietal pain to localize to one
or more abdominal quadrants .
• Sharp, severe, and well localized.
• The anterior and lateral abdominal wall is innervated from
vertebral segments T7 to L1, whereas the posterior abdominal
wall is from L2 to L5.
Parietal pain :
– Triggered by :
• Irritation of the parietal peritoneum by an inflammatory process
(e.g., chemical or bacterial).
• Mechanical stimulation, such as a surgical incision.
Referred pain
• Arises from a deep visceral structure but is
superficial at the presenting site i.e. pain felt at a remote
area from the diseased organ .
• It results from central neural pathways that are
common to the somatic nerves and visceral organs
i.e. misinterpretation of visceral afferent impulse that cross
the nerve cells to the corresponding somatic dermatome
within the CNS .
• Radiating pain is pain in remote area but in
continuity with the diseased organ .
Lump & Ulcer
•
•
•
•
•
•
•
When did u notice it ?
How did u notice it?
What are the associated symptoms ?
Persistence ( does it ever disappear ?)
Progression ( change in its size )
Any other lump currently or previously
What do u think the cause ?
Questions