TO ALL OF MY COLLEAGUES• Nobody can teach you, unless you try to learn• A teacher cannot teach u all the time, he can expose your ignorance only.• Don’t expect too much from a teacher because his knowledge is limited.• Rather, try to learn from the books under the guidance of your teacher.• Never compromise quality in learning. As the future( treating & teaching ) will be in your hand.• We may not be excellent , but have the scope to excel.
INTRODUCTION• History taking skills is very much essential in medical curriculum.• Objectively being tested in formal exams• Forms the basis of reaching a correct diagnosis• Often ignored/ proper emphasis is not applied by many of us.
IMPORTANCE• In HT we evaluate the feelings of a person.• Sometimes we evaluate the Gestures when a pt. is unable to express his feelings.• Is there any equipment developed so far to measure or assess the feelings & gestures of man (patient)?• Therefore HT & PE forms the foremost aspect of Medical Science.• It is considered as an Art.
• HT –a process to assess feelings.• Feelings- symptoms of diff. diseases.• - cannot be quantitated nor expressed in sc. terms• Scientific understanding of disease- body changes in terms of changes in anatomy & physiology.• HT- assess bodily changes & its affect on mind.• Non – verbal communications• Body language- no physical ailment, but symptomatic.
Importance of History Taking• Obtaining an accurate history is the critical first step in determining the etiology of a patients problem.• A large percentage of the time ) 70%), you will actually be able make a diagnosis based on the history alone.
General Approach Introduce yourself. • Note – never forget the patient names • Be friendly and relaxed with the Patient. •Respect Patient Confidentiality & Privacy. Try to see things from patient point of view. Understand the patients mental status, anxiety, irritation or depression. Always exhibit neutral position. Always Listen to the Patient. Questioning: simple/clear/avoid medical terms/open, leading, interrupting, direct questions and summarizing.
KEY POINTS1.To take a good history, one has to go down to the level of thinking thept2. To identify the exact nature of work of the pt. & how the illnessaffects his day to day work.3.Understanding the language of the pt. is mandatory for correctassessment of history.4. Encourage him to speak freely without any reservation.5. Create an environment for free talk6. One should be attentive while listening the pt.,do not get diverted.7.Do not show displeasure or dissatisfaction.8. Privacy is important, no outsiders should be allowed.9.Duty of the doctor is to collect a reliable history.10. Always try to greet the pt. by name whenever possible.11.Try to discuss topics unrelated to his ailment.
KEY POINTS 12. If a pt. is giving unnecessary details of a minor point, do not getirritatated, listen patiently & simultaneously ask details of points youfeel to be important.13.Dissuade pts. Or attendants from speaking medical terms withoutknowing the significance & meaning.14.Dicourage pts. To tell about their t/t & show several consultation &inv. papers.15. Tell them to show them after the end of the conultation, becausethese papers may misguide the DIAGNOSIS.16. Critical ill pts.- save the life of the pt. first with min. history, stabilisehim, then collect data from relatives.Gasping pt.- No history, treatment always precedes diagnosis.
THE LEADING QUESTIONLeading question is that which suggests its answer, usually as yes orno.Leading questions lead to diagnosis.These questions to be asked to pts. who do not give a cohesivehistory.Answers to these questions to cross verified, about their reliabilityOften the pt. replies in yes, to emphasise his complaints& replies in NO if he wants to hide some points.
FROM WHOM HISTORY TO BE COLLECTED1. Only the patient in ordinary situations.2. Interference by relatives to discouraged .3. Children- Parents, preferably the mother.4. Unconcious Pt- persons who were present at the onset of illness5. Transient loss of consciousness- TIA,Epilepsy – Eye witness6. Mental retarded/Deaf & Dumb- Care- takers
OBSERVATION OF NVC NON-VERBAL COMMUNICATIONSWhile the pt. is narrating his historyObserve pt. closely - words he uses/emotional attachment to the words - movement of hand & body parts etc, should be noticed.EXAMPLESIf the pt. is weeping,signifies severity of pain- ANGINAL PAINMoving his hands over sternum- RETROSTERNAL IN SITEMoving his hands over a wide area of abd.- ABDOMINAL PAINPoints site of pain with finger- LOCALISED PAIN-PLEURISYGroaning with abd. Pain- COLICKY PAINCloth tied over head or abd. – HEADACHE OR COLICKY AB.PAINTalking in a loud voice- NERVOUS OR DEAFTalking in low voice & looking at this side or other- SEX. PROBLEMWearing warm dress in summer- FEVERUnable to complete a sentence in one breath- low VCGiving extensive details of illness/t/t - HYPOCHONDRIAC
FOR SUCCESSFUL HISTORY TAKINGLIKE ANY OTHER ART ,PRACTICE MAKES A MANPERFECTSO ALSO IN THE ART OF HISTORY TAKING ONE HAS TOPRACTICE DAILY TO IMPROVE.THE MORE ONE FEELS FOR THE PATIENT, THE MORE HEGETS INVOLVED WITH HIM , THE MORE HE EXTRACTSINFORMATIONS FROM HIM (PATIENT)SENSE OF FEELING & INVOLVEMENT WITH THE PATIENTIS THE SOLE CRITERIA FOR A SUCCESSFUL HT.
KEY ELEMENTS• Introduce your self (name and position)• Make a rapport with patient• Beginning: ‘ Tell me what brought you to hospital’• Middle stem : Follow structured format• End: Summarise and ‘Have you got anything else to add or say?’
First Impressions• Positive Impression – Appearance – Confidence – Demeanor – Body Language
Session Structure1. Personal Information 5min2. Chief complaints Pair Group and Role Play 10min3. History of present illness 10min4. History of Past Illness 10min5. Systemic enquiry 10min6. Family history 10min7. Drug & Treatment history 10 min8. Social history9. Others 10min
. 1.Personal Information• Always record personal details: – Name, – Age, – Address, – Sex, – Ethnicity – Occupation, – Religion, – Marital status. – Date of examination – ASK WHETHER PT IS CASH OR CREDIT – REFD. BY WHOM
Personal Information Age:Children 1.Congenital:- Coarctation Bicuspid AV 2. Inborn errors of Metabolism 3.Nutritional deficency: Kwashiorkor, Marasmus, Vit.A Def. 4.Other Common Problems: FB in ENT 5.Bleeding PR-Rectal polyp
Personal Information Sex:• Important factor towards the causation of disease: – In Females: » Endocrine disorders » Rheumatoid, SLE, Collagen diseases In Males: Transmitted as x-linked Haemophilias Colour blindness Gout due to def. in HGPRT enzyme. Duchenne type muscular dystrophy Smoking & alcohol – Multiple Myeloma
Personal Information Locality• Environmental factors: – Dis. Related to Genetic constitution Chaga’s disease: Brazil, Argentina, Uruguay Sleeping sickness: Central & West African Thalassaemia : Mediterranean countries. Multiple sclerosis & Sub.ac combined degn Temperate Climate Of Spinal chord & Pernicious anaemia : Carcinoma stomach : Japan
Personal Information Locality• Khangri cancer : kashmir• Goitre : Sub- Himalayan – largest belt in world• Fluorosis : A.P,TN,Punjab, Harayana,Karnataka• Kalazar :Bihar & WB• Dracunculosis : Rajasthan• Bancroftian filariasis : Orissa, AP,TN,kerala.
Personal Information :Occupation• Pneumoconiosis• Silicosis(silicon dusts) sand blasting , ceramic industry .• Anthracosis (Coal workers)• Asbestosis (Asbestos workers)• Byssinosis (Textile workers)• Brucellosis : Vetenarians• Anthrax : carrying animal skins on their back.• Leptospirosis : Sewerage workers• Lead toxicity : Lead industries Hypoplastic Anaemia : Exposure to Benzene chemicals. Hypopalstic anaemia / leukaemia :Prolonged exposure X-Rays Psittacosis and ornithosis. Bird handlers
2.Chief Complaints & History of Present Illness• The C/C are complaints that brings the pt. for medical help.• U can suggest a few words or phrases to the pt. so that becomes meaningful.• All c/c should be recorded chronologically.( as all symp. May be manifestations of 1 illness at diff. stages or related to the other as a cause & effect.• Usually a single symptom, 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?
History of Present Illness - Tips• Elaborate on the chief complaint in detail• Ask relevant associated symptoms• Have differential diagnosis in mind• Lead the conversation & thoughts• Decide & weigh the importance of minor complaints
History of Present Illness - Tips• Avoid medical terminology & make use of a descriptive language that is familiar to them• Ask OPQRSTA for each symptom
Pain (OPQRST)Onset of diseasePosition/siteQuality, nature, character – burning sharp, stabbing, crushing; alsoexplain depth of pain – superficial or deep.Relationship to anything or other bodily function/position.Radiation: where moved toRelieving or aggravating factors – any activities or position Severity – how it affects daily work/physical activities. Wakes him up at night, cannot sleep/do any work.Timing – mode of onset (abrupt or gradual), progression(continuous or intermittent – if intermittent ask frequency/nature.)Treatment received or/and outcome.Are there any associated symptoms? .
Chief Complaints• EXAMPLE 1.• A patient may come for haemoptysis (say for 2 days), but he fails to tell that he was having cough for two months.• Alarming symptom: Haemoptysis Here the cough hasn’t been complained by the patient, it has been extracted from him. His C/C : Cough- 2 m, Haemoptysis – 2 days Pulmonary tuberculosis: Bronchogenic carcinoma
EXAMPLE 2.• Case 2- Haematemesis – 2days• On further asking it was revealed that having fever with joint pain – 5 days• Illness started with fever with joint pain• To get relief took analgesics – erosive gastritis-• Haematemesis• Therefore – haematemesis is not a part of original illness , but is a complication of t/t
True complaints• Fever -5 days• Joint Pain – 5 days• Haemetemesis – 1 day• Sometimes pt may c/o D yspnoea at rest &• Palpitation – 5 days• But on enquiry it was revealed that he is having dyspnoea since 5 yrs• Dyspnoea – 5yrs/ DAR- 5d/ Palpitation-5d
THE STARTING COMPLAINT• Always emphasis should be given to collect the correct starting complaint.• What was the 1st comp.when the pt. felt unwell.• With the progress of the illness, more & more symptoms get added to the starting complaint.• Eg: Unconscious pt. with fever & neck rigidity• - meningitis or S.A haemorrhage• If 1st cc is Severe headache – S.A.H• If 1st cc is Fever -Meningitis
THE STARTING COMPLAINT• Ex: 2• A woman with advanced Preg.+Convulsions+LOC• Fever on O/E ( Eclampsia or Encephalitis)• Episodic convulsions+ High BP – Fever- ECLAMPSIA• 1st C/C is Fever , then Convulsions – Encephalitis
Duration of illness: Tips• Exact duration of illness• if in months & years –onset is gradual –chronic problem• if in days / hrs- onset is sudden – acute problem• if episodic – epilepsy, bronchial asthma,CCF, AE of COPD• OTHER PERTINENT POINTS:• For how long you are ill.• When you were completely normal.• Is this complain for the first time or you have other episodes.
Ascertaining the Genuine nature of complaint• Always try to verify whether c/c is genuine or not.• Convulsions-• Do not get confused with restlessness + abnormal limb movements• Associated features-tongue bite,involuntary passage of urine,twisting of the head,rolling of eye ball• BREATHLESSNESS• If a man doing physical labour complains of breathlessness its genuine nature can be verified by asking how much effects his work.• No more able to work, genuine.
Ascertaining the Genuine nature of complaint• Weight loss• Often people exaggerate the complaint of weight loss.• This is not always acceptable or believable.• Ask the patient, what was previous weight and when it was recorded ?• From the present weight you can calculate the weight loss over that period.• This can also be assessed fairly well from the clothing.• Once significant weight loss is established, very likely there is a genuine illness.
Ascertaining the Genuine nature of complaint• Appetite• Frequently patients complain of loss of appetite.• Ask th person who serves food to him.• What is his usual food habit (quantity and quality) any change or not in this habit can be ascertained from them.• Vomiting• Fictitious vomiting.• He might be bringing out little amount of saliva might be retching only.• Ask the pt. to collect all the vomitus and produce before you.
Ascertaining the Genuine nature of complaint• Fever and Chill• Record the temperature.• Type of fever - intermittent.. Continuous or chills Administration of antipyretics.• Maintain a temperature chart at least four to six times a /week• Then proceed for investigation.• Remember that if there is recorded fever in any case, there is an organic illness.
Ascertaining the Genuine nature of complaint• Haemoptysis and Haematemesis• Confusion,cough,nausea,vomiting,melaena,colour of blood presence or absence of clot or food metarial, froth will help to decide.• Amount of blood loss.• Absence of melaena.• Poisoning• Always assess the amount of poison consumed from the physical signs.• The time gap between the intake and examination• Vomited after intake time.• Intake of the poison and gastric lavage.• Received any treatment period.
Circumstances under which the Disease Started • The details of the circumstance under which the illness started will give valuable clue to the diagnosis. • Diabetes mellitus - hypoglycemic coma • Malaria endemic area few days Delhi epidemic -dengue fever.
Associated Complaints• More than one complaint told by the patient gets frankly revealed by tactful questioning.• These associated complaints help maximum in reaching at the diagnosis.
QUESTION & ANS. SESSIONS Question ?1.Fever associated with cough and expectoration ?
Negative History• Significant negative history should be told in relevant cases.• Unconscious patient complete absence of fever exclude infective condition.• Absence of syncope angina aortic valve disease, convulsion, absence of head injury and intoxication should be mentioned.• Ascending paralysis -absence of animal bite.
History of Past illness• Effect relationship with present illness.• Guide the treatment of the present illness.• History of similar illness.• History of significant illness.• Hypertension, diabetes mellitus, tuberculosis and syphilis should be included as these conditions can affect many organs.
History of Past illness• Ask the patient or his relatives to enumerate all the major illnesses he has suffered from childhood including major accidents and surgeries. From them one has to screen out which is important which is not.• Produce the documents related to previous illness.• The patient given history example - rheumatic fever, what age it occurred, joints were affected, how severe was the joint pain, fleeting penicillin prophylaxis.
Collecting History of Diabetes Mellitus• Symptoms like polyuria, polyphagia and polydipsia.
Collecting History of Tuberculosis• Previous treatment records, X-rays, sputum examination reports.• Previous history of prolonged fever, persistent cough, hemoptysis, weight loss.• The drugs prescribed antitubercular drugs.
History of Hypertension• In a country like india history of hypertension is obtained in a confusing manner.• Like reeling of head.• Always emphasis should be given to produce the documentary evidence of hypertension.• Names of the drugs.• If a normal recording of blood pressure is found always ascertain whether the patient is no the drugs or off the drugs.
History of STD • Syphilis in earlier days was the single most important disease to involve almost all organs. • Primarily it is a sexually transmitted disease.• AIDS - History contact - Blood Transfusion - Any injection pride
6.Family History• Certain diseases are likely to occur in many members of the family.• Genetically transmitted diseases.• Familial clustering of diseases.
Family History• Any familial disease/running in families e.g. breast cancer, IHD, DM, schizophrenia, Developmental delay, asthma, albinism.• Infections running in families as TB, Leprosy.• Cholera, typhoid in case of epidemics.
Genetically Transmitted Disease• There are many diseases which are transmitted genetically.• Genetically transmitted condition can occur in a person without similar illness in the family due to mutation.• A particular condition may not express completely in all cases (full expression or partial expression).• History of consanguineous marriage the family
Autosomal Dominant Disorders• Adult polycystic kidney disease• Multiple neurofibromatosis.• Hereditary spherocytosis.• Familial hypercholesterolemia.• Acute intermittent porphyria and so on.
9. Personal/ Social History• Food Habits• Malnutrition allergy or intolerance.• Excess of coffee -Reflux oesophagitis• Excess of tea - Supraventricular ectopics• Vegetarian -vitamin B12 deficiency• Dietary toxins with Khesari dal -(Lathyrism)
Social & Personal History• Smoking history - amount, duration & type.• A strong risk factor for IHD• Alcohol history - amount, duration & type.• Occupation, social & education background, ADL, family social support& financial situation.• Social class.• Home conditions as: • Water supply. • Sanitation status in his home & surrounding.• Animals / birds in his/her house.
Social History: smoking• The most important cause of preventable diseases.• Smoking history - amount, duration & type.• Amount: pack”year calculations.• Duration: continuous or interrupted.• Any trials of quitting & how many.• Deep inhalation or superficial.• Active or passive smoker.• Type: packs, self-made, Cigars, Shesha , chewing etc.
Addiction and Habituation• Alcohol• GI system – gastritis, pancreatitis, fatty liver, hepatitis, cirrhosis of liver, the nervous system, peripheral neuropathy, Korsakoff’s psychosis, cerebellar degeneration, dementia.• Smoking – Chr.Bronchitis, Broncho.Ca.,CAD,• Gudakhu• Oral tobaco – oral cancer
Addiction and Habituation• Opium – Constipation - Do not respond to analgesics and sedatives.• Drugs - Narcotics and benzodiazepines abuse• Sleep – Insomnia – unfavourable environment - Physical illness, orthopnoea, or any painful condition• Excessive sleep – Alcohol, sedatives, hypothalamic, disorders, Pickwickian syndrome.• Reversal sleep Rhythm (night time insomnia & day time somnolence – old age
Bowel and Bladder Recent change in Bowel habits – Colorectal.caRecent onset of diarrhoea – infectiveBLADDER HABITS- Women evacuate bladder less frequently than males.-Disturbances in bladder habit takes several forms like-Increased frequency of urination, polyuria, oliguria,hesitancy, urgency, dysuria, incontinence, retention, etc.
Socioeconomic Status• Poor SES status – Various infection, infestations, nutritional def.• High SES status – sedentary lifestyle, obesity & related problems.
7.Drug & Treatment History• Drug History (DH)• Always use generic name or put trade name in brackets with dosage, timing &how long.• Example: Ranitidine 150 mg BD PO• Note: do not forget to mention: OCT/Vitamins/Traditional /Herbal medicine & alternative medicine• Blood transfusion.• ALLERGY OR SENSITIVE DO DRUGS.• ANY T/T OR SURGERY
Menstrual & obstetrics History• Gyn/Obstetric history if female• Gravida, para, abortions, C- sections, antenatal care & screening for Hep B & C.• Menarchy & Menopause• Menstrual cycles• LMP
Other Relevant History• Immunization if small child• Note: Look for the child health card.• Travel / sexual history if suspected STDs 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)This is a guide not to miss anythingAny significant finding should be moved to HPC orPMH depending upon where you think it belongs.Do not forget to ask associated symptoms of PresentComplaints with the System involvedWhen writing up patient notes, record the systemsreview so that the relieving doctors know what systemyou covered.
System ReviewGeneral•Weakness•Fatigue•Anorexia•Change of weight•Fever/chills•Lumps•Night sweats
System ReviewCardiovascular•Chest pain•Paroxysmal Nocturnal Dyspnoea•Orthopnoea•Short Of Breath(SOB)•Cough/sputum (pinkish/frank blood)•Swelling of ankle•Palpitations•Cyanosis
System ReviewGastrointestinal/Alimentary•Appetite (anorexia/weight change)•Diet•Nausea/vomiting•Regurgitation/heart burn/flatulence•Difficulty in swallowing•Abdominal pain/distension•Change of bowel habit•Haematemesis, melaena, haematochezia•Jaundice
System ReviewRespiratory System•Cough(productive/dry)•Sputum (colour, amount, smell)•Haemoptysis•Chest pain•SOB/Dyspnoea•Tachypnoea•Hoarseness•Wheezing
System ReviewUrinary System•Frequency•Dysuria•Urgency/strangury•Hesitancy•Terminal dribbling•Nocturia•Back/loin to groin pain•Incontinence•Character of urine: colour/ amount (polyuria)& timing•Fever
System ReviewNervous System•Visual/Smell/Taste/Hearing/Speech problem•Headache•Fits/Faints/Black outs/loss of consciousness•Muscle weakness/numbness/paralysis•Abnormal sensation•Tremor•Change of behaviour or psyche.•Paresis.
System ReviewGenital system•Pain/ discomfort/ itching•Discharge•Unusual bleeding•Sexual history•Menstrual history – menarche/ LMP/duration & amount of cycle/Contraception/ menopause/PMB•Obstetric history – Para/ gravida/abortion
System ReviewMusculoskeletal System•Pain – muscle, bone, joints•Swelling•Weakness/movement•Deformities•Gait
SOAP 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 signs, physical examination/daily weight,fluid balance,diet/lab. investigation and interpretation Assessment – address each active problem after making a problem list. Make differential diagnosis. Plan – about management, treatment, further investigation, follow up and rehabilitation
SUMMARY1.PERSONAL INFORMATION2. CHIEF COMPLAINTS3.HISTORY OF PRESENT ILLNESS4.HISTORY OF PAST ILLNESS5.FAMILY HISTORY6.PERSONAL /SOCIAL HISTORY7. DRUG & TREATMENT HISTORY8.MENSTRUAL & OBTETRICS HISTORY9.SYSTEMIC REVIEW10.TO REACH APROVISIONAL DIAGNOSIS
ERROR IN HISTORY TAKINGWrong or incomplete historyImproper sequence of history takingIdentification of malingeringIgnoring the family & RelativesNot maintaining privacy