History Taking

Dr. Mustafa NemaConsultant Physician

Baghdad College of Medicine2014

Objectives

• Define clinical history.

• Make a firm idea about the importance of clinical history.

• Learn the art of history taking.

• Explain the steps of history taking.

Introduction

Three things for accurate diagnosis

History

Tests

Exam.

Why people visit doctors?

• They have reached their limits of tolerance

• They have reached their limits of anxiety

• They have problems of daily living presenting as symptoms

• For prevention

• For administrative reasons

History taking resembles the “head” of medicine “body”

"Listen to your patient, he is telling you the diagnosis,“ (Osler 1919)

The diagnosis could be achieved by history-taking alone in the majority of patients. (Platt -

1947).

-

History taking is an art!

Clinical history is similar to the art of collection of randomly distributed small pieces of a large picture in order to form the complete one.

Art of listening

• Patients want more than merely intellectual and technical proficiency.

• Most patients want a doctor who listens to them.

Definition

• A medical history is the collection of data obtained by interviewing the patient.

• It looks simple, but taking a medical history is truly an art.

Structure of history

1. Personal

(demographic)

information

2. General information

3. Chief complaint

4. History of present

illness

5. Review of systems

6. Past medical

7. Family/Personal

8. Social history

1. Personal (demographic) information

• Name

• Age

• Sex ( to be presented to others, especially when the name is confusing)

• Address

• Occupation

• Marital Status

2. General information

• Date of entry to the hospital

• Source (and reliability) of informant

– Relative

– Friend

– Other..

• Hospital record number (optional)

3. Chief complaints (CC）

المريض دعت الرئيسية التيالرئيسي أو الشكوى السبب -.لمراجعة الطبيب ومدتها

• What problems brought the patient to the doctor and for how long was that?

Example: cough for 7 days.

• It is a “brief” description of the reason for today's visit for example:

– Symptom ( e.g. headache)

– Conditions (e.g. high blood pressure)

– Follow up

etc..

4. History of Present illness (HOPI)

بدايتها الى وقت من -الطبية تفاصيل المشكلة السؤال عن -. بتفاصيلها وبتسلسلها الزمني -المقابلة

The story of the problem(s) from when first started to the present “in own words”.

It is usually stated in the patient's own words.

• The HOPI is a “chronological” description of the present illness from the first sign or symptom to the present.

You need to identify the main presenting symptom with the some details that include:

– Onset

– Duration

– Periodicity

– Severity

– Relieving factors

– Precipitating factors

– Site & radiation (of pain)

– Other relevant directly connected feature

• Enquires about ‘associated symptoms’ (i.e. other symptoms directly related to the system(s) of the presenting complaint) including important negatives.

5.Review of Systems (ROS)

.الجسممراجعة اوضاع باقي أجهزة -

• An ROS is a listing of any signs or symptoms the patient may be experiencing or has experienced organized by body system.

• The ROS is not a detailed history. It is a review of systems directly related to the problem(s) identified in the HPI.

ROS include the following systems:

1. Nervous System:

Headache, Coma, Convulsions, Blurred Vision, Decreased Hearing, Difficulty With Speech, Dysphagia, Limb Weakness, Sphincter Disturbances , Parasthesia ,Anesthesia.

2. Cardiovascular System:

Chest Pain, Dyspnea, Orthopnea, Paroxysmal Nocturnal Dyspnea, Leg Oedema, Palpitation.

3. Respiratory System:

Cough, Dyspnea, Chest Pain, Wheezes, Sputum, Hemoptysis, Cyanosis

4. Gastrointestinal System And Liver:

Dysphagia, Heartburn, Dyspepsia, Vomiting, Hematemesis , Abdominal Pain, Diarrhoea, Costipation, Melena, Bleeding Per Rectum, Jaundice, Pale Stool, Dark Urine.

5. Urinary system:

Loin Pain, Polyuria , Nocturia, Polydypsia, Frequency, Dysurea, Oligurea, Hematuria, Pyurea,hesitancy, Urgency, Drippling, Retension, Incontinence

6. General:

Fever, Rigor, Appetite, Weight, Sweating.

7. Musculoskeletal System:

Arthralgia, Arthritis, Myalgia, Bone Pain, Back pain.

8. Mucucutaneous symptoms:

Hair loss, Skin rash , Itching, Bleeding spots, Mouth ulcers, sore throat, epistaxis.

9. Menestrual And Obstetric History:

Menarche, Menstrual Cycle, Menorrhagia, Amenorrhoea, Menopause, Number of Pregnancies, Abortions, Type of Delivery.

10. Psychiatric History:

Mood, Daily Activity, Sleep.

6.Past medical History

• Illness: like diabetes, hypertension, asthma, TB

• Drugs use:

– name of the drug(s), dose, duration, compliance, herbal medicines.

– Ask specifically on: allergy to penicillin, sulpha, or any other drug

– Use of coricosteroid

• Hospitalization: for medical/surgical cause

• Trauma

• Blood transfusion

• Childhood diseases

• Allergies: drugs, asthma, food, skin, and any other material

7. Family History

• ‘Are there any illnesses that run in your family?’. Ask specifically for DM, HT, asthma and TB.

• Is there similar illnesses?

• Follow up the presenting complaint, e.g. when your patient has heart disease, ask ‘Is there any history of heart disease in your family?’

Also ask about family members:

– Father

– Mother

– Each sibling

– History of disease in which heredity or contact may play a role

Many illnesses are associated with a positive family history.

• Marital History

– Married, single or widow?

– Age and health )of the husband/wife)

– Year of marriage

– Ages and health of children

– Previous marriages

– Record a family tree

8. Social History

• The social history helps you to understand the context of the patient’s life and possible relevant factors

Social history include:

• Residence(s) area and home life

• Animal contact

• Water supply

• Education

• Occupation

• Habits：– Use of tobacco

– Drinking alcohol

– Other drugs

Please note!

• The basis of a true history is good communication between doctor and patient.

• The extent of information obtained and documented will vary with the nature of the problem.

• Identifies effects of the symptoms on the patient psychological, social state.

• Elicits patient's beliefs and expectations

• Summarizes important information back to patient.

• Appropriate communication skills.

• Take a moment and think about what types of questions are asked. (They are very personal).

• Certain responses may result in life-altering consequences (e.g., surgery).

Summary

• Clinical history is collection of data from your patient.

• History taking is the most vital part in medical practice.

• Many parts constitute the structure of history.

• We must experience the history as an art of medicine.

Further readings

• Macleod’s clinical examination. 13th ed, 2013.

• Platt, R., Manchester University School Gazette, 1947,27,139

• Patient.co.uk

• http://www.oslersymposia.org/about-Sir-William-Osler.html.

Thank you