REVISION ON HISTORY TAKING.ppt

1. REVISION ON ADULT AND PEDIATRIC HEALTH HISTORY
BY AKLILU GETACHEW (MD)
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2. REVISION ON HISTORY TAKING
 Objectives
◦ To clarify about clinical evaluation of a patient
◦ To revise on basic techniques of hx taking
◦ To revise on contents & relevance of all components of comprehensive
health history
◦ To see difference b/n Adult & pediatrics hx taking
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3. Clinical evaluation
 Comprises of health history & P/E
 Core of patient evaluation
 Made based on Hx taking & P/E skills
 Importance of clinical evaluation
70%-80% of diagnosis is made by it.
Guides next step or it is base for investigation based evaluation.
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4. THE HEALTH HISTORY
 Is a record of clinical event
 Concerned with symptoms
Symptoms; are subjective complaints noted & told by a
patient.
e.g. cough, chest pain, shortness of breath, vomiting,
diarrhea constipation
fever, loss of appetite, loss of weight
 Guides physical examination.
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5. Hx Taking/ Conducting an Interview
Has four main components
1. Greeting the patient and Establishing Rapport
2. Skilled Interview (supportive interview)
3. Taking Notes
4. The Closing
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6. 1. Greeting the patient establishing Rapport
◦ Greet the patient and introduce yourself
◦ Maintain Confidentiality
◦ Arrange the room
◦ Give your undivided attention
2. Making skilled Interview
◦ Interview should be more flexible, focused & problem
oriented.
◦ Should be more fluid & will follow patients leads & cues.
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7. Components of the techniques of Skilled History
taking
a) Adaptive Questioning ; based on patients verbal and non
verbal cues
uses d/t options to clarify patients story
 Directed Questioning; from general to specific & should be open
ended.
N.B avoid leading questions.
 Questioning to elicit graded response
 Asking series of questions one at a time
 Offering multiple choices for answer
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b) Adaptive listening; process of fully attending what a patient
is communicating
-it needs practice
c) Facilitation; maintaining the flow of the patient’s story
- made by actions (nodding head, leaning forward) or
words (Go.. on. ”I’m listening’’)
d) Echoing ; simple repetition of patient’s word
e) Empathic Response; sharing patient’s feelings & responding
accordingly.

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f)Validation; making the patient feel his/her emotions are
understandable
g) Reassurance; should be made at the end.
h) Summarization; giving summery of the story.
-it indicates to the patient that u’r listening
-helps to know what you know & don’t know
-allows to organize clinical reasoning

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3. Taking Notes
-Jot down short phrases, specific dates or words.
-don’t let note taking distract you from the patient.
-keep good eye contact
4. The Closing
-a time to encourage the patient to discuss any additional
problems, or to ask any question.
-but, don't answer questions if you aren’t sure.

11. Components of Comprehensive Health History
 Listed in standard format of CASE REPORT
 Structure patient’s story & format of written document.
 N.B - order shouldn’t dictate sequence of interview (technique of
history taking should be flexible)
 Preferably organization of information in to formal written format
should be after the interview & examinations are completed.
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12. Order of Case Recording.
1. Identification of the patient
2. Previous Admissions
3. Chief complaints
4. History of the present Illness
5. Past Illness
6. Functional Inquiry ( System Review)
7. Personal &Social History
8. Family History
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13. 1. Identification of the patient
-Date Time -Full Name
-Date of Admission
-Age & Sex -Ward
-Address -Bed No
-Occupation
-Religion
2. Previous Admissions; list of hospitalization in the order
they occurred.
-Specify the date, name & location of the hospital. the
disease that led to admission & the outcome.
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14. 3. Chief complaint (s)
 Is the main complaint that brought the patient to seek medical
care.
 Should be simple, brief,& recorded with duration of each
symptoms using patients word.
 If there are >2 C/C ,should be listed in order of occurrence.
 The question can be put as “what is the main problem that has
brought you to hospital?”
e.g. shortness of breath / 3 weeks
Not dyspnea
chest pain / 1 week
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15. 4. History of present Illness
 It is detailed description of the chief complaint in relation to its
mode of onset &development of illness in chronological order.
 Details of the chief complaint should include;
1. Date of onset :- it is often useful to start the HPI with a
phrase “the patient was relatively well until…” from then on ,the
development of signs & symptoms, expressed as chief
complaint, should be traced in detail to the present time.
2. Mode of onset
-Sudden/Abrupt
-Insidious/Gradual
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16. 3. Character (elaboration or analysis of symptoms)
 Examples
1.common complaints
a. Pain (PQRST)
-Place (location)
-Quality (dull aching,sharp,burning or stabbing)
-Radiation
-Severity (mild ,moderate, sever)
-Temporal
b. Fever – Grade (low/high)
_Course (Intermittent/Persistent)
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17. 2.Common cardio-respiratory symptoms
a. Shortness of Breath
-How does it come on?/what degree of exertion produce it?
-Does it wake up the patient at night? (PND)
-Does the patient has to sit up/require more pillows while lying supine?
(Orthopnea)
b. Cough
-Quality (Dry/Productive of sputum)
-Character (Hacking, Barking, Whooping)
-Timing (Morning/Nocturnal)
C. Sputum
-Color &Consistency (Serous, Purulent ,Mucoid, Frothy & Mucopurulent)
-Odor (foul smelling, or Not)
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d . palpitation
-What brings it ?(Exertion/Spontaneous)
-How long it lasts ?
e. Chest pain (PQRST)
f. Body Swelling (edema)
-Pattern of spread
-Time interval
3. Common GI & Renal Complaints
a. Vomiting
-Pattern ( Projectile/ Non Projectile )
-Amount & Color (Bilious /Non Bilious )
-Content (Blood, Feculent, Ingested food)
-Frequency

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b. Diarrhea
-Consistency & Color (watery, Bloody, mucous containing)
-Frequency
c. Abdominal Swelling (Distension)
-Initial Site
-Progression (rapid/gradual)
-Associated symptoms
d. Urinary Symptoms
Urine
-amount
-Color
-Frequency
-Pain during urination

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4. Aggravating & Relieving factors
5. Course of symptoms
-persistent /continuous
-Short lived /constant
-Intermittent / on-off
-Steady /Increasing in severity
6. Effect of Treatment & Medications
-Mode of treatment
Conservative (Life style modification)
Medications (Name, dose,Frequency)
Allergies
-Effect of Treatment

21. 7. “Negative-Positive Statement”
 Includes completion of review of affected / suspected system (s) ,&
inquiry in to other related system, as well as, medicinal, hereditary,
environmental, & other conditions related to the C/C.
 Aim is to construct DDX.
 Positive statements include
-associated symptoms
-risk factors
-precipitating factors
-predisposing factors
 Negative statements:-used to rule out DDx.
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22. 8. Strength & Weight Changes
- Stated in the last paragraph of HPI
-Strength-how the patient came
-Weight change
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23. 5.Past illness
 Lists childhood illnesses
 Lists adult illnesses with dates for at least
four categories: medical; surgical; obstetric/
gynecologic; and psychiatric
 Includes health maintenance practices such
as: immunizations, screening tests,
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24. 6. Functional Inquiry ( System Review)
 Is a detailed account of symptoms referable to each system of the
body.
 Can be made while examining the patient.
 Has the following main advantages
-Uncover problems that the patient overlooked---Gives Clear
understanding of the HPI.
-Allows to group important symptoms that need to be considered
with the present complaint.
-it also helps to include important Negative statement.
 Standard series of review of system Questions
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25. 1. Head, Eyes, Ears, Nose, Throat (HEENT).
 Head: Headache, head injury, dizziness lightheadedness
 Eyes: Vision, glasses or contact lenses, last
examination, pain, redness, excessive tearing, double vision,
blurred vision,.
 Ears: Hearing, tinnitus, vertigo,
earaches, infection, discharge. If hearing is decreased, use or
nonuse of
hearing aids.
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. Nose and sinuses:, nasal stuffiness, discharge, or itching, bleeding
per nose
Throat (or mouth and pharynx):
Condition of teeth, bleeding gums,
sore tongue, frequent sore throats.
. Neck. Lumps, “swollen glands,” goiter, pain, or stiffness in the neck.
Breasts. Lumps, pain or discomfort, nipple discharge,
Respiratory. Cough, sputum (color, quantity), hemoptysis,
dyspnea,wheezing.

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, Cardiovascular
chest pain or discomfort, palpitations, dyspnea, orthopnea,
paroxysmal nocturnal dyspnea,edema
Gastrointestinal., nausea, vomiting, excessive belching ,heartburn,
loss of appetite, Pain up on swallowing
 change in bowel habits, (diarrhea constipation ) rectal bleeding or
black or tarry stools, hemorrhoids,,. Abdominal pain passing of gas.
Urinary. Frequency of urination, polyuria, nocturia, urgency, burning or
pain on urination, hematuria, hesitancy,
dribbling.

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Integumentary System (skin, hair & Nail)
Dry or Moist Skin, rashes, ulcers, hair distribution & pigementary
changes, changes in finger nails
Musculoskeletal. Muscle or joint pains, stiffness, swelling,
redness,,, weakness, or limitation of motion or activity backache.
 history of trauma.
Neurological. Fainting, blackouts, seizures, weakness, paralysis,
numbness
 or loss of sensation, tingling or “pins and needles,” tremors or
other involuntary movements.

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. Genital. Male:, discharge from or sores on the penis, testicular
pain or masses, history of sexually transmitted diseases and their
treatments.
Female: Gynecologic Hx
Vaginal discharge, itching, ulcer ,dyspareunia ,birth control methods, &
Exposure to HIV.
.Age at menarche; regularity, frequency, and duration of periods;
amount of bleeding, bleeding between periods or after intercourse,
dysmenorrhea, age at menopause, menopausal symptoms,
Obstetric Hx
. No of pregnancies, No & type of deliveries, abortions

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 7.Personal History
 Early development:-place of birth, child hood development,
activities, social & economic status.
 Education
 Environment
 Social Activities &Habits
 Marital Status:- Health of husband (wife), No
Of Children &their health.
 8. Family History
-father & mother’s; Age, health (if dead, cause of
death)
-Siblings list with ages, health (if dead, cause of
death)
-Familial disease (hypertension, Diabetes, Asthma)

31. PEDIATRIC HEALTH HISTORY
Similarities with Adult Health
History
 In Basic Techniques of history
Taking.
 In most of the contents of
comprehensive health history.
 Differences from Adult Health
History
 History is obtained Indirectly from
care taker.
 The History has some peculiar
components
-Immunization Hx
-Nutritional Hx
-Developmental Hx 31

32. Contents of pediatric history
1. Personal Details
2. Chief complaint
3. Chief Complaint
4. History of Present Illness
5. Past Medical Illness
6. Family History
7. Immunization History
8. Nutritional History
9. Developmental History
10. Review of Systems
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1.Personal details (ID)
 Patients Identification
-Name
-Age
-Sex
-Address
-Ward & Bed No
 Historian’s Identification
- Name
-Age
-Sex
-Occupation
-Religion

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2. Chief Complaint
3.History of present Illness
4.Past Medical Illness
-Mother’s` Prenatal, Labor &Delivery Hx
-Child’s Neonatal, Infancy & Childhood’s Hx
-Medical Illnesses Measles, Pertussis, Mumps, Chickenpox
-Surgical conditions & Medications
5.Family History
-Social History Housing, family size, Income, water supply &
waste disposal.

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6. Medical Hx:- list of siblings & their health statu----Familial Disease
7.Immunization History
-when started?, types, time interval & route of Administration
- Should be assed based on EPI Schedule
8.Nutritonal History
-Breast feeding (EBF/not, frequency & total duration)
-Complementary feeding ( when started? ,type of meal, frequency &
duration)
-Exposure to sun Light
-Current diet (type & frequency)

36. 8.Developmental History
 Assessed based on the four Spheres of development
(Developmental Milestones) for that Particular age
-Gross Motor dev’t:-includes control of head, trunk &
extremities
-Fine Motor dev’t:-includes the dev’t of finger movements
-Language dev’t:- production of sounds, words,&
understanding others.
-Social Dev’t:- identification of objects,& persons ,ability to play
with others
9.Review of Systems
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Thank You for Being Patient
Till the End