Principles of History Taking

8/3/2019 Principles of History Taking

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Principles ofPrinciples of historyhistory takingtaking


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Reviewing the Chart:Reviewing the Chart:

TheThe medicalmedical chartchart givegive youyou valuablevaluable

informationinformation aboutabout pastpast diagnosisdiagnosis andand

treatmenttreatment YouYou shouldshould looklook atat thethe identifyingidentifying datadata

(age,(age, gender,gender, address,address, maritalmarital status,status,

healthhealth insurance,insurance, thethe medicationmedication list,list, thethe

documentationdocumentation ofof allergies)allergies)


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Clinicians BehaviorsClinicians Behaviors

AsAs youyou observeobserve thethe patientpatient throughtthrought thethe

interview,interview, thethe patientpatient willwill bebe watchingwatching youyou

You You shouldshould bebe sensitivesensitive toto thosethose messagesmessages

andand managemanage themthem asas wellwell asas youyou cancan

Posture,Posture, gesture,gesture, eyeeye contact,contact, andand wordswords cancan

expressexpress interest,interest, attention,attention, acceptance,acceptance, andand

understandingunderstanding TheThe skilledskilled interviewerinterviewer seemsseems calmcalm andand

unhurried,unhurried, eveneven whenwhen timetime isis limitedlimited


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Clinicians AppearanceClinicians Appearance

Cleanliness, neatness and a name

tag are reassuring to the patient.

Remember that you want the patient

to trust you


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Note takingNote taking

You need to write down much of what

you learn in a health history

The EnviromentThe Enviroment

Make the setting as private as possible


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Learning about the Patients iIlnessLearning about the Patients iIlness

Greeting the PatientGreeting the Patient

GreetGreet thethe patientpatient andand introduceintroduce yourselfyourselfbyby namename

IfIf thisthis isis thethe firstfirst contact,contact, clarifyclarify youryourrole,role, suchsuch asas statingstating youryour statusstatus asas aastudentstudent andand explainingexplaining youryour relationrelation toto

thethe patientspatients carecare WhenWhen otherother individualsindividuals areare present,present, askask

thethe permissionpermission ofof thethe patientpatient toto conductconductthethe interviewinterview inin frontfront ofof themthem


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The Patients ComfortThe Patients Comfort

Be alert to the patients comfort


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Comprehensive historyComprehensive history

Data and time of history: the date isData and time of history: the date is

importantimportant

Identifying data: including age, gender,Identifying data: including age, gender,maritual status and occupationmaritual status and occupation

Source of history: such as patient, family,Source of history: such as patient, family,

friend, officer, consultant, medical recordfriend, officer, consultant, medical record Chief complaintsChief complaints


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Present illnesPresent illnes

Current medication: including dose andCurrent medication: including dose and

frequency of usefrequency of use AllergiesAllergies

Past historyPast history

Childhood illnesses: such as measles,Childhood illnesses: such as measles,rubella, mumps, whooping cough, chickenrubella, mumps, whooping cough, chicken

pox, rheumatic fever, poliopox, rheumatic fever, polio


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Adult illnesses:Adult illnesses:

MedicalMedical

1.1. Diabetes mellitusDiabetes mellitus2.2. HypertensionHypertension

3.3. HepatitisHepatitis

4.4. AsthmaAsthma

5.5. HIVHIV


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Adult illnesses:Adult illnesses:

Surgical: include dates, indication, outcomeSurgical: include dates, indication, outcome

Obstetric/ Gynecologic: inculde obstetricObstetric/ Gynecologic: inculde obstetrichistory, menstruation history, birth control,history, menstruation history, birth control,

number and gender of partners, atnumber and gender of partners, at--riskrisk

practisespractisesPsychiatric: include dates, diagnosis,Psychiatric: include dates, diagnosis,

hospitalisations, treatmenthospitalisations, treatment


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Current health statusCurrent health status

Tobacco (type used, amount and duration ofTobacco (type used, amount and duration of

use)use)

Alcohol (type used, amount and duration ofAlcohol (type used, amount and duration of

use)use)

Drugs (type used, amount and duration ofDrugs (type used, amount and duration of

use)use)


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Current health statusCurrent health status

Exercise and dietExercise and diet

Immunisations:Immunisations:

1.1. TetanusTetanus

2.2. PertussisPertussis

3.3. DiphteriaDiphteria

4.4. PolioPolio

5.5. MeaslesMeasles

6.6. RubellaRubella7.7. MumpsMumps

8.8. InfluenzaInfluenza

9.9. Hepatitis BHepatitis B


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Family historyFamily history

Age and health, or age and couse of death ofAge and health, or age and couse of death of

each immediate family members (parents,each immediate family members (parents,

siblings, spouse, and children)siblings, spouse, and children)

Date of grandparents and grandchildrenDate of grandparents and grandchildren

may also be usefulmay also be useful


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Diabetes mellitusDiabetes mellitus

Heart diseaseHeart disease

HypercholeterolemiaHypercholeterolemia High blood pressureHigh blood pressure

StrokeStroke

Kidney diseasesKidney diseases


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ArthritisArthritis

AnemiaAnemia

AllergiesAllergies AsthmaAsthma

HeadachesHeadaches

Mental illnessMental illness


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TuberculosisTuberculosis

CancerCancer

DrugsDrugs EpilepsyEpilepsy


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Personal and Social HistoryPersonal and Social History

Occupation and educationOccupation and education

Home situationHome situation

Daily lifeDaily life

Leisure activites/hobbiesLeisure activites/hobbies


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Present illnessPresent illness

The principal symptoms should be discribed inThe principal symptoms should be discribed interms of:terms of:

1.1. LocationLocation2.2. QualityQuality

3.3. Quantity and severityQuantity and severity

4.4. TimingTiming

5.5. Factors that have aggrevated or relievedFactors that have aggrevated or relieved

themthem


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Review of systemsReview of systems

General:General:

Weight, recent weight changeWeight, recent weight change

WeaknessWeakness FatiqueFatique

FeverFever


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Skin:Skin:

Rashes,Rashes,

lumps,lumps, sores,sores,

itching,itching,

dryness,dryness, color changecolor change

Hair and nails changesHair and nails changes


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HeadHead: headache, head injury, dizziness: headache, head injury, dizziness

EyesEyes: vision, glasses, contact lenses, pain,: vision, glasses, contact lenses, pain,

redness, dryness, double vision, spots,redness, dryness, double vision, spots,flashing lights, glaucoma, cataractaflashing lights, glaucoma, cataracta

EarsEars: hearing, vertigo: hearing, vertigo

Nose an sinusesNose an sinuses: frequent cold, nasal: frequent cold, nasalstuffiness, hay fever, sinus troublestuffiness, hay fever, sinus trouble


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Mouth and throutMouth and throut: condition of teeth, gums, bleeding: condition of teeth, gums, bleedinggums,sore tonque, dry mouth, frequnt sore throats,gums,sore tonque, dry mouth, frequnt sore throats,hoursenesshourseness

NeckNeck: lumps, swollen glands,goiter pain: lumps, swollen glands,goiter pain

BreastBreast: lumps, pain and discomfort: lumps, pain and discomfort

RespiratoryRespiratory: cough, sputum (color quantity): cough, sputum (color quantity)

hemoptysis, dyspnea, wheezing, asthma, bronchitis,hemoptysis, dyspnea, wheezing, asthma, bronchitis,emphysema, pneumonia, tuberculosisemphysema, pneumonia, tuberculosis,,


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CardiacCardiac::

heart trouble,heart trouble,

high blood pressure,high blood pressure, rheumatic fever,rheumatic fever,

heart murmurs,heart murmurs,

chest pain or discomfort,chest pain or discomfort, palpitations, dyspnoe, orthopnoe,palpitations, dyspnoe, orthopnoe,

paroxysmal nocturnal dyspnoe, edemaparoxysmal nocturnal dyspnoe, edema


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GastrointestinalGastrointestinal::

Trouble swallowingTrouble swallowing

HeartburnHeartburn AppetiteAppetite

NauseaNausea

VomitingVomiting RegurgitationRegurgitation

Vomiting of bloodVomiting of blood


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GastrointestinalGastrointestinal::

Bowel movementsBowel movements

Color and size of stoolsColor and size of stools

Change of bowel habitsChange of bowel habits

Rectal bleedingRectal bleeding

Black tarry stoolsBlack tarry stools

HemorrhoidsHemorrhoidsConstipationConstipation

DiarrheaDiarrhea


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Gastrointestinal:Gastrointestinal:

Abdominal painAbdominal pain

Food intoleranceFood intoleranceJaundiceJaundice

Liver or gallbladder troubleLiver or gallbladder trouble

hepatitishepatitis


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Urinary:Urinary:

Frequency of urinationFrequency of urination

PolyuriaPolyuria

NocturiaNocturia Burning or pain on urinationBurning or pain on urination

HematuriaHematuria

UrgencyUrgency

Reduces caliber or force if the urinary streamReduces caliber or force if the urinary stream IncontineceIncontinece

stonesstones


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GenitalGenital::

Female:Female:

Age at menarcheAge at menarche RegularityRegularity

FrequencyFrequency

Duration of periodsDuration of periods Amount of bleedingAmount of bleeding

Last periodLast period


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Genital:Genital:

Femal:Femal:

DysmenorrheaDysmenorrhea

Premenstrual tensionPremenstrual tension Age at menopausaAge at menopausa

ItchingItching

Sexually transmitted diseasesSexually transmitted diseases

Number of pregnanyciesNumber of pregnanycies Number and type of deliveryNumber and type of delivery

Number of abortionNumber of abortion


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Genital:Genital:

Male:Male:

HerniasHernias Testicular painTesticular pain

Sexually transmitted diseasesSexually transmitted diseases


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Periferla vascular:Periferla vascular:

Intermitten claudicationIntermitten claudication

Leg crampsLeg cramps Varicose veinsVaricose veins

Past clots in the veinsPast clots in the veins


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Musculoskeletal:Musculoskeletal:

Muscle pain, weaknessMuscle pain, weakness

Joint painJoint pain StiffnessStiffness

ArthritisArthritis

GoutGout

BackacheBackache


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Neurologic:Neurologic:

1.1. SeizeresSeizeres

2.2. WeaknessWeakness3.3. ParalysisParalysis

4.4. Numness or loss of sensationNumness or loss of sensation

5.5. TremorTremor


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HematologicHematologic

AnemiaAnemia

Easy bruising or bleedingEasy bruising or bleeding Past transfusionPast transfusion


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EndocrineEndocrine

Thyroid troubleThyroid trouble

Heat or cold intoleranceHeat or cold intolerance Excessive sweatingExcessive sweating

DiabetesDiabetes

Excessive thirst or hungerExcessive thirst or hunger

polyuriapolyuria


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Establishing RapportEstablishing Rapport

TheThe initialinitial contactcontact withwith thethe patientpatient setssets thethe foundationfoundationforfor thethe relationshiprelationship

GoodGood interviewinginterviewing techniquetechnique allowsallows patientspatients totorecountrecount theirtheir ownown storiesstories spontaneouslyspontaneously

You You shouldshould listenlisten activelyactively andand watchwatch forfor cluesclues totoimportantimportant symptoms,symptoms, emotionsemotions events,events, andandrelationshipsrelationships

YouYou cancan thanthan guideguide thethe patientpatient intointo tellingtelling youyou moremore

aboutabout thethe areasareas thatthat seemseem mostmost significantsignificant.. ThisThis isis donedone byby usingusing directdirect questioningquestioning

QuestiontsQuestionts shouldshould proceedproceed fromfrom thethe generalgeneral toto thethespecificspecific


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Sometimes patients seem quite unable to describeSometimes patients seem quite unable to describetheir symptoms without helptheir symptoms without help

Offer multipleOffer multiple--choice answerschoice answers Is your pain Is your pain achingaching,,sharp, pressing, burning, shooting, or whatsharp, pressing, burning, shooting, or what??

Use lanquage that is undestandable and appropiate toUse lanquage that is undestandable and appropiate to

the patientthe patient Establishing the sequence and time course of theEstablishing the sequence and time course of the

patients symptoms is importantpatients symptoms is important

You can encourage a chronologic account by suchYou can encourage a chronologic account by suchquestions asquestions as What thanWhat than? or ? or What happened nextWhat happened next??


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Generating and TestingGenerating and Testing

Diagnostic HypothesesDiagnostic Hypotheses AsAs youyou learnlearn aboutabout thethe patientspatients storystory

andand thethe symptoms,symptoms, youyou shouldshould bebegeneratinggenerating hypotheseshypotheses aboutabout whatwhat bodybody

systemssystems mightmight bebe involvedinvolved byby aapathologicpathologic processprocess

ForFor example,example, legleg pain,pain, suggestssuggests aaproblemproblem inin thethe peripheralperipheral vascular,vascular,musculoskeletal,musculoskeletal, oror nervousnervous systemsystem


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11.. ItsIts locationlocation..WhereWhere isis it?it? DoesDoes itit radiate?radiate?

22.. ItsIts qualityquality.. WhatWhat isis itit like?like?

33.. ItsIts quantityquantity oror severityseverity.. HowHow badbad isis it?it?

44.. ItsIts timingtiming.. WhenWhen diddid oror doesdoes itit start?start?

HowHow longlong doesdoes itit last?last? HowHow oftenoften doesdoes ititcome?come?

55.. TheThe settingsetting inin whichwhich itit occurs,occurs, includingincludingenviromentalenviromental factors,factors, personalpersonal activities,activities,

emotionalemotional reactionsreactions.. 66.. FactorsFactors thatthat makemake itit betterbetter oror worseworse..

Principles of History Taking

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