Basic Concepts of History Taking.pptx

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Basic concepts ofhistory taking

Dr. Made Ratna Saraswati, SpPD

Tuesday, 12 Oct 2010


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References

Bickley LS, Szilagyi PG, 2009.

Bates Guide to Physical Examination and History

Taking, 10thedition.

Lippincot William and Wilkins, Philadelphia.

Lloyd M & Bor R, 2004.

Communication Skills for Medicine. Churcill

Livingstone, New York


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Patient - Doctor

A patient brings to doctor theirproblems, usually in the form of

symptoms or complain

The doctors role is to gain asaccurate as possible, a picture of the

patients problem


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Developing a management plan for a

patient

Lloyd M & Bor R, 2004. Communication Skills for Medicine. Churcill Livingstone,

Establish

a relationship

with a patient

Gather information:

History

Physical examination

Investigation

Make a diagnosis if

possible

Formulate a management

plan

Explain and

discuss this with

the patient


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Rene Laennec

(French physician)

Listen to the patient.

They are giving you thediagnosis


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Diagnosis changed after investigation

Diagnosis changed after physicalexamination

Fig. Relative contribution of history, physical

examination, and investigations to final diagnosis

83%

8%

9%


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Determining the scope of

your assessment

How much should I do?

Should my assessment be

comprehensive or focused?


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Comprehensive assessment Focused assessment

Bickley LS, Szilagyi PG, 2009. Bates Guide to Physical Examination and History Taking, 10 thedition. Lippincot William andWilkins, Philadelphia.


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Is appropriate for a new patient in the office

of hospital

Provides fundamental and personalized

knowledge about the patient

Strengthens the clinician-patient

relationship

Helps identify or rule out physical causes

related to patient concerns

Provides baselines for future assessment

Creates platform for health promotionthrough education and counseling

Develops proficiency in the essential skills

of physical examination



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Is appropriate for a new patient in the office

of hospital

Provides fundamental and personalized

knowledge about the patient

Strengthens the clinician-patient

relationship

Helps identify or rule out physical causes

related to patient concerns

Provides baselines for future assessment

Creates platform for health promotionthrough education and counseling

Develops proficiency in the essential skills

of physical examination

Is appropriate for established

patients, especially during

routine or urgent care visits

Addresses focused concerns

or symptoms

Assesses symptoms

restricted to a specific bodysystem

Applies examination

methods relevant to

assessing the concern of

problem as precisely andcarefully as possible



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Differences between subjective and

objective data

Subjective data Objective data

What the patient tells you

The history, from chief

complaint through review ofsystems

What you detect during the

examination

All physical examination finding



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Differences between subjective and

objective data

Subjective data Objective data

What the patient tells you

The history, from chief

complaint through review ofsystems

Example:

Mrs. G is a 54 years old

hairdresser who reportspressure over her left

chest, which goes into her

left neck and arm.

What you detect during the

examination

All physical examination finding

Example:

Mrs. G is an older, overweight

female, who is pleasant andcooperative, height 154cm, weight

62 kg, BMI 26.14, blood pressure

160/80, heart 96 and regular,

respiratory rate 24, temperature

365o

CBickley LS, Szilagyi PG, 2009. Bates Guide to Physical Examination and History Taking, 10 thedition. Lippincot William andWilkins, Philadelphia.


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The seven components of the

Comprehensive Adult Health History

1. Initial information:

identifying data and source of the history

2. Chief complaint (s)

3. Present illness

4. Past history

5. Family history

6. Personal and social history

7. Review of the systems


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1. Initial information

Date and time of history:the date is always important, be sure todocument the time you evaluate the patientespecially in urgent, emergent, or hospital setting

Identifying data:

age, gender, occupation, marital status

Source of history:

usually the patient, but can be a family memberor friend, letter of referral, or the medical record

If appropriate, establish source of referralbecause a written report may be needed.

Reliability:

Varies according to the patients memory, trust,and mood


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2. Chief complaint (s)

The one or more symptoms or

concerns causing the patient to seek

care Quote the patients own words


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3. Present illness

Each principal symptom should be wellcharacterized with seven attributes

1. Location

2. Quality3. Quantity or severity

4. Timing, including onset, duration, andfrequency

5. The setting in which it occurs6. Factors that have aggravated or relieved the

symptom

7. Associated manifestation


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May include

(which are frequently pertinent to the

present illness):

Medications

Allergies

Habits of smoking

Alcohol and drug


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4. Past history

List childhood illnesses

List adult illnesses

1. Medical

2. Surgical

3. Obstetric/gynecologic

4. Psychiatric

Includes health maintenance

practices


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5. Family history

Outlines or diagrams age and health,or age and cause of death, of siblings,

parents, and grandparents, children

and grandchildren. Specific illnesses in family

History of cancer

Genetically transmitted disease


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6. Personal and social history

Captured the patient personality, interest, sources of support,coping style, strength, and fears.

Occupation

Last year of schooling/education

Home situation and significant others

Source of stress

Important life experiences

Leisure activities

Religious affiliation and spiritual beliefs

Activities of daily living (ADL)

Lifestyle habits that promote health of create risk

Describes educational level, family of origin, current

household, personal interest, and lifestyle


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7. Review of the systems

Documents presence or absence ofcommon symptoms related to each

major body system


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Writing up the patients notes

The notes should be written clearlyand concisely under the same

headings used for taking the patient

history


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Modifying the history taking

sequence

It is important to learn and practice the

history taking sequence. By taking a

history in structure, you are less likelyto miss important information.

However you will need to modify in

some situation.


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Some practical hints

Take every opportunity you are given tointerview

Be prepared to spend time with patient

Skill:

Establish rapport

Listen actively

Ask mainly open question

Pick up and respond to verbal and non-verbal

cues Summarize and check for accuracy

Make an aide memoire sequence

Take note


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