Principles of History Taking Dr Thamer Bin Traiki.

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 misleadingProblem 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. Site2. Time & mode of onset3. Duration4. Severity5. Nature ( Character)6. Progression of pain7. The end of pain8. Relieving factors9. Exaggerating (Exacerbating) factors10. Radiation11. 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