History taking

1. Introduction and Describing Aim &Objectives 20 min
2. Chief complaint 10min
3. History of present illness 10min
4. Past medical history 10min
5. Systemic enquiry 10min
6. Family history 10min
7. Drug history 10min
8. Social history 10 min
PairGroupandRolePlay

 Aim:
› At the end of the session students should
know fundamentals of history taking and take
a history of a simple disease
 Objectives:
At the end of the session students should
record:
› Chief complaint
› Present illness
› Past medical history
› Systemic enquiry
› Family history
› Drug history
› Social history

 Obtaining an accurate history is the
critical first step in determining the
etiology of a patient's illness
 A large percentage of the time ) 70%),
you will actually be able make a
diagnosis based on the history alone.

 The sense of what constitutes important
data will grow exponentially in future as you
learn about the pathophysiology of disease
 You are already in possession of the tools
that will enable you to obtain a good
history.
 An ability to listen and ask common-sense
questions that help define the nature of a
particular problem.
 A vast and sophisticated fund of
knowledge not needed to successfully
interview a patient.

Introduce yourself.
•Note – never forget patient names
•Creat patient appropriately in a friendly relaxed way.
•Confidentiality and respect patient privacy.
General ApproachGeneral Approach
Try to see things from patient point of view. Understand
patient underneath mental status, anxiety, irritation or
depression.
Always exhibit neutral position.
Listening
Questioning: simple/clear/avoid medical terms/open, leading,
interrupting, direct questions and summarizing.

.
 Always record personal details:
› name,
› age,
› address,
› sex,
› ethnicity,
› occupation,
› religion,
› marital status.
› Record date of examination

 Chief complaint
 History of present illness
 Past medical history
 Systemic enquiry
 Family history
 Drug history
 Social history

 The main reason push the pt. to seek for
visiting a physician or for help
 Usually a single symptoms, occasionally
more than one complaints eg: chest pain,
palpitation, shortness of breath, ankle
swelling etc
 The patient describe the problem in their
own words.
 It should be recorded in pt’s own words.
 What brings your here? How can I help
you? What seems to be the problem?

Cheif Complaint (CC)Cheif Complaint (CC)
 Short/specific in one clear sentence
communicating present/major problem/issue.
 Timing – fever for last two weeks or since
Monday
 Recurrent –recurring episode of abdominal
pain/cough
 Any major disease important with PC e.g. DM,
asthma, HT, pregnancy, IHD:
 Note: CC should be put in patient language.

 Elaborate on the chief complaint in
detail
 Ask relevant associated symptoms
 Have differential diagnosis in mind
 Lead the conversation and thoughts
 Decide and weight the importance of
minor complaints

Sequential presentation
•Always relay story in days before admission e.g. 1 week before the
admission, the patient fell while gardening and cut his foot with a stone.
•Narrate in details – By that evening, the foot became swollen and patient
was unable to walk. Next day patient attended Khorshid hospital and
they gave him some oral antibiotics. He doesn’t know the name. There
is no effect on his condition and two days prior to admission, the foot
continued to swell and started to discharge pus. There is high fever and
rigors with nausea and vomiting.
History of Presenting Complaint(HPC)History of Presenting Complaint(HPC)
In details of symptomatic presentation
•If patient has more than one symptom, like chest pain, swollen legs and
vomiting, take each symptom individually and follow it through fully
mentioning significant negatives as well. E.g the pain was central
crushing pain radiating to left jaw while mowing the lawn. It lasted for
less than 5 minutes and was relieved by taking rest. No associated
symptoms with pain/never had this pain before/no relation with food/he
is Known smoker,diabetic & father died of heart attack at age of 45.
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 them
 Describe each symptom in
chronological order

Pain (OPQRST)Pain (OPQRST)
Position/site
Severity – how it affects daily work/physical activities. Wakes
him up at night, cannot sleep/do any work.
Relationship to anything or other bodily function/position.
Radiation: where moved to
Relieving or aggravating factors – any activities or position
Quality, nature, character – burning sharp, stabbing, crushing;
also explain depth of pain – superficial or deep.
Timing – mode of onset (abrupt or gradual), progression
(continuous or intermittent – if intermittent ask frequency and
nature.)
Treatment received or/and outcome.
Onset of disease
Are there any associated symptoms? Check with SR.

 Start by asking the patient if they have
any medical problems
 IHD/Heart Attack/DM/Asthma/HT/RHD,
TB/Jaundice/Fits :E.g. if diabetic- mention time
of diagnosis/current medication/clinic check up
 Past surgical/operation history
 E.g. time/place/ and what type of operation.
Note any blood transfusion and blood grouping.
 History of trauma/accidents
 E.g. time/place/ and what type of accident

 Drug History (DH)
 Always use generic name or put trade
name in brackets with dosage, timing
and how long. Example: Ranitidine
150 mg BD PO
 Note: do not forget to mention
OCP/Vitamins/Traditional
medicine/KAP

 bd (Bis die) - Twice daily (usually morning and
night)
 tds (ter die sumendus)/tid (ter in die) = Three
times a day mainly 8 hourly
 qds (quarter die sumendus)/qid (quarter in die)
= four times daily mainly 6 hourly
 Mane/(om – omni mane) = morning
 Nocte/(on – omni nocte) = night
 ac (ante cibum) = before food
 pc (post cibum) = after food
 po (per orum/os) = by mouth
 stat – statim = immediately as initial dose
 Rx (recipe) = treat with

 Any familial disease/running in families
e.g. breast cancer, IHD, DM,HTN
schizophrenia, Developmental delay,
asthma etc.

 Smoking history - amount, duration and
type. A strong risk factor for IHD
 Drinking history - amount, duration and
type. Cause cardiomyopathy,
vasodilatation
 Occupation, social and education
background, ADL, family social support
and financial situation

 Gyane/Obstetric history if female
 Immunization if small child
 Note: Look for the child health card.
 Travel and sexual history if suspected STI or
infectious disease
 Note:
 If small child, obtain the history from the care
giver. Make sure; talk to right care giver.
 If some one does not talk to your language, get
an interpreter(neutral not family friend or
member also familiar with both language). Ask
simple & straight question but do not go for yes
or no answer.

System Review (SR)System Review (SR)
This is a guide not to miss anything
Any significant finding should be moved to HPC or PMH
depending upon where you think it belongs.
Do not forget to ask associated symptoms of PC with the
System involved
When giving verbal reports, say no significant finding on
systems review to show you did it. However when writing
up patient notes, you should record the systems review so
that the relieving doctors know what system you covered.

System ReviewSystem Review
Respiratory System
•Cough(productive/dry)
•Sputum (colour, amount, smell)
•Haemoptysis
•Chest pain
•SOB/Dyspnoea
•Tachypnoea
•Hoarseness
•Wheezing
Cardiovascular
•Chest pain
•Paroxysmal Nocturnal Dyspnoea
•Orthopnoea
•Short Of Breath(SOB)
•Cough/sputum (pinkish/frank blood)
•Swelling of ankle(SOA)
•Palpitations
•Cyanosis
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, haematochagia
•Jaundice
General
•Weakness
•Fatigue
•Anorexia
•Change of weight
•Fever
•Lumps
•Night sweats

System ReviewSystem Review
Urinary System
•Frequency
•Dysuria
•Urgency
•Hesitancy
•Terminal dribbling
•Nocturia
•Back/loin pain
•Incontinence
•Character of urine:color/ amount
(polyuria) & timing
•Fever
Nervous System
•Visual/Smell/Taste/Hearing/Speech
problem
•Head ache
•Fits/Faints/Black outs/loss of
consciousness(LOC)
•Muscle weakness/numbness/paralysis
•Abnormal sensation
•Tremor
•Change of behaviour or psyche
Genital system
•Pain/ discomfort/ itching
•Discharge
•Unusual bleeding
•Sexual history
•Menstrual history – menarche/ LMP/
duration & amount of cycle/
Contraception
•Obstetric history – Para/ gravida/abortion
Musculoskeletal System
•Pain – muscle, bone, joint
•Swelling
•Weakness/movement
•Deformities
•Gait

SOAPSOAP
Subjective: how patient feels/thinks about him. How does
he look. Includes PC and general appearance/condition of
patient
Objective – relevant points of patient complaints/vital
sings, physical examination/daily weight,fluid
balance,diet/laboratory investigation and interpretation
Plan – about management, treatment, further investigation,
follow up and rehabilitation
Assessment – address each active problem after making a
problem list. Make differential diagnosis.

History taking

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History taking