History taking as foundation of clinical diagnosis.

1. By,
Dr. Vinuta Patil
Department of PG studies in Roga Nidana
JSSAMC Mysore
HISTORY TAKING AS FOUNDATION OF CLINICAL
DIAGNOSIS

2. 2
What is history taking?
It is a process by which information is gained by a
physician by asking specific questions to the Patient
with the aim of obtaining information useful in
formulating a diagnosis and providing medical care to
the patient.

3. 3
IMPORTANCE OF HISTORY TAKING:
1. Obtaining an accurate history is the critical first step
in determining the etiology of patient’s problem.
2. 70% you will be able to make a diagnosis based on
the history alone.
3. Also, history taking helps to find the cause for the
patients condition.

4. Steps in case history taking.
4
 Introduce yourself
* Never forget patient names.
* Create patient in a friendly relaxed way.
* Confidentiality and respect patient privacy.
 Try to see from patient point of view. Understand patient
problem and mental status.
 Listen patiently
 Questioning : Simple / clear/ avoid medical terms/ direct
questions and summarizing.

5. 5
 Analyze and interpret the assembled clues to reach the
provisional diagnosis.
 Make a differential diagnosis of all possible complications.
 Plan a effective treatment accordingly.

6. COMPONENTS:
6
 Patients Data
 Chief complaint
 History of Present illness
 Past medical history
 Family history
 Social history
 Systemic review

7. 1. Patient Data:
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 Name:
Identification
To communicate with the patient
Record maintenance
Age:
For diagnosis
Treatment planning
Certain disease occurs at different age groups for e;g

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Disease more
commonly present at
birth
Disease present in
children& young adults
Disease present in
adults & older patient
Cleft lip & Cleft palate Dental Caries Fibroma
Teratoma Diptheria Ameloblastoma
Ankyloglossia Rickets Iron deficiency anaemia
Infectious Mononucleosis Diabetes, Hypertension,
Asthma

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 Gender
Disease common in males:
Leukoplakia, cancer like Squamous cell carcinoma,
Melanoma, lymphoma etc.
Disease common in Female:
Iron deficiency anaemia, sjogren’s syndrome, recurrent apthous
ulcers etc
Drug interaction: In female , special consideration must be given
to pregnancy .

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 Address :
• For future contact
• Prevalence of disease
 Occupation:
• To asses the socioeconomic status
• Prediction of disease in different occupation for eg: Lung
fibrosis in industrial workers
 Marital status:
• The high consanguinity rates, coupled by the large family size
in some communities could induce the expression of
autosomal recessive disease.

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 Date :
Time of admission
Reference during follow up visits
Record maintenance
 Registration number :
Maintaining a record
Billing purpose
Medico legal aspects

12. 2. Chief complaint:
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 The Main reason push the patient to seek for visiting a physician or for
help.
 It is started in patients own words in chronological order of their
appearance and their severity.
 It should be Short / specific in one clear sentence
E:g = Fever - 2 weeks
Chest pain - 1 week
Vomiting - 2days
 The chief complain aid in the diagnosis and treatment planning and
should be given the first priority.

13. 3. History of present Complaint (HPC) :
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 Elaborate the chief complaint in detail.
 Ask relevant associated symptoms.
 Have differential diagnosis in mind.
 Lead the conversation and thoughts, Decide and weight the
importance of minor complaints.
 In details of present with, time of onset/ mode of evolution/
any investigation , Treatment and outcome, any associated
positive or negative symptoms.

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 Avoid medical terminology and make use of a
descriptive language that is familiar to them and
describe each symptoms in chronological order.
 Each symptom should be explored in more detail
for clarification because this help to more accurate
description of the patient’s problem. direct
questions can be used to ask about:

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 Site
• Somatic pain, often well localised, e.g. sprained ankle
• Visceral pain, more diffuse, e.g. angina pectoris.
 Onset
• Speed of onset and any associated circumstances
 Character
• Described by adjectives, e.g. sharp/dull, burning/tingling,
/ stabbing, crushing, preferably using the patient’s
own description.

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 Radiation
• Through local extension
• Referred by a shared neuronal pathway to a distant unaffected
site, e.g. diaphragmatic pain at the shoulder tip via the phrenic
nerve (C3, C4)
 Associated symptoms
• Numbness in the leg with back pain suggesting nerve root
irritation.

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 Timing (duration, course, pattern)
• Since onset
• Episodic or continuous:
• If episodic, duration and frequency of attacks
• If continuous, any changes in severity
 Aggravating and relieving factors
• Effects of specific activities or postures, including effects of
medication and alternative medical approaches

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 Severity
• Difficult to assess, as so subjective
• Sometimes helpful to compare with other common pains, e.g.
toothache

19. 4. Family History:
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 Start with open questions, such as ‘Are there any
illnesses that
run in your family?’ Follow up the presenting symptoms
with a question like ‘Have any of your family had heart
trouble?’
Single-gene inherited diseases are relatively uncommon in
Clinical practice. Even when present, autosomal recessive
diseases such as cystic fibrosis usually arise in patients with
healthy parents who are unaffected carriers.

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Many other illnesses are associated with a positive
family history but are not due to a single-gene disorder.
 Certain disease run in families – Diabetes, cancer-
breast, thyroid, piles, peptic ulcer etc, should be
noted.
 Enquire about family members – Alive, dead ,
current illness.

21. 5. Past medical history
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 Past medical history may be relevant to the presenting symptoms:
for example, It may reveal predisposing past or underlying illness,
such as diabetes in a patient with peripheral vascular disease, or
childhood whooping cough in someone presenting with bronchiectasis.
These questions will elicit the key information in most patients:
 What illnesses have you seen a doctor about in the past?
 Have you been in hospital before or attended a clinic?
 Have you had any operations?

22. Drug History:
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 This follows naturally from asking about past illness. Begin
by checking any written sources of information, such as the
drug list on the referral letter or patient record. It is useful to
compare this with the patient’s own recollection of what they
take.
 Write down the name , Dosage, Duration of therapy, and long
term medication, Current medication, Adverse reactions,
allergies.
 E:g= Drug Dosage Duration Side effects
Aspirin 75Mg 5 Years Indigestion

23. 6. Social history
23
 No medical assessment is complete without
determining the social circumstances of your
patient. These may be relevant to the causes of their
illness and may also influence the management and
outcome.
 Smoking history:
Among other things, tobacco use increases the risk
of obstructive lung disease, cardiac disease, peptic
ulceration, intrauterine growth restriction, erectile
dysfunction and a range of cancers.

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 Most patients recognise that smoking harms health, so
obtaining an accurate history of tobacco use requires
sensitivity. Ask if your patient has ever smoked; if so, enquire
what age they started at and whether they still smoke now.
Patients often play down recent use, so it is usually more
helpful to ask about their average number of cigarettes per day
over the years, and what form of tobacco they have used.
Convert to ‘pack-years’ to estimate the risk of tobacco-related
health problems.

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 Do not forget to ask non-smokers about their exposure to environmental
tobacco smoke (passive smoking).
 Calculating pack-years of smoking
A ‘pack-year’ is smoking 20 cigarettes a day (1 pack) for 1 year
Number of cigarettes smoked per day × Number of years smoking
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 For example, a smoker of 15 cigarettes a day who has smoked for
40 years would have smoked: 15 ×40 = 30 packs-years
20

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 Alcohol causes extensive pathology, including not only
hepatic cirrhosis, encephalopathy and peripheral neuropathy
but also pancreatitis, cardiomyopathy, erectile dysfunction and
injury through accidents. Always ask patients if they drink
alcohol but try to avoid appearing critical, as this will lead
them to underestimate their intake. If they do drink, ask them
to describe how much and what type (beer, wine, spirits) they
drink in an average week. The quantity of alcohol consumed
each week is best estimated. in units; 1 unit (10 mL of
ethanol) is contained in one small glass of wine, half a point
of beer , or one standard measure (25 mL) of spirits.

27. Occupational history
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 Work profoundly influences health. Unemployment is
associated with increased morbidity and mortality while some
occupations are associated with particular illnesses .Ask all
patients about their occupation. Clarify what the person does
at work, especially about any chemical or dust exposure.

28. Examples for occupational history:
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Occupation Factor disorder Presents
Engineers,
Plumbers,Heati
ng workers
Asbestos dust Pleural plaques,
Lung cancer,
Asbestosis
≥ 15 years later
Industrial
worker
Chemical e;g
Chromium
Excessive
noise, vibrating
tools
Dermatitis on
hands , Hearing
loss.
over month
Health worker Cuts , needle
stick injuries
Human
immunodeficien
cy virus,
Hepatitis B and
C
Incubation
period ≥
3months

29. 7. Systematic enquiry: cardinal symptoms
29
The final part of history taking involves performing a systemic
enquiry. This involves asking questions about the other
body systems not discussed in the presenting complaint.
The purpose of this to check that no information has been
omitted.

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It involves systematic questioning of symptoms
Relating to cardiovascular, respiratory,
gastrointestinal, Genitourinary, locomotor
aspects are important clues about the cause of
the presenting problems.

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
 General health
* Wellbeing * Energy
* Sleep * Appetite
* Weight change * Mood
 Cardiovascular system
* Chest pain
*Breathlessness
* Orthopnoea

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 Respiratory system
• Shortness of breath (exercise tolerance)
• Cough
• Wheeze
• Sputum production (colour, amount)
• Blood in sputum (haemoptysis)
• Chest pain (due to inspiration or coughing)

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 Gastrointestinal system
• Mouth (oral ulcers, dental problems)
• Difficulty swallowing (dysphagia – distinguish from pain on
swallowing, i.e. odynophagia)
• Nausea and vomiting
• Heartburn
• Abdominal pain
• Change in bowel habit
• Change in colour of stools (pale, dark, fresh blood)

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 Genitourinary system
• Pain passing urine (dysuria)
• Frequency passing urine (at night: nocturia)
• Blood in urine (haematuria)
• Sexual partners – unprotected intercourse
 Men
If appropriate:
• Prostatic symptoms, including difficulty starting (hesitancy):
• Urethral discharge
• Erectile difficulties

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 Women
• Last menstrual period (consider pregnancy)
• Timing and regularity of periods
• Length of periods
• Abnormal bleeding
• Vaginal discharge
• Contraception
If appropriate:
• Pain during intercourse (dyspareunia)

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 Nervous system
• Headaches
• Altered sensation
• Weakness
• Visual disturbance
• Hearing problems (deafness, tinnitus)
• Memory and concentration change

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 Musculoskeletal system
• Joint pain, stiffness or swelling
• Mobility
• Falls
 Endocrine system
• Heat or cold intolerance
• Change in sweating
• Excessive thirst (polydipsia)

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 Differential diagnosis :
The process of listing out of two or more disease
having similar signs and symptoms of which only one
could be attribute to the patients disease.

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 Final diagnosis :
The Final diagnosis can usually be recorded
Following chronological organization and
critical evaluation of the information obtained
from the - Patient history, Physical examination
and the result of investigation.

40. Conclusion:
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In history taking careful enquiry should be conducted till
sufficient clues are obtained to come with diagnostic conclusion
with rich deferential diagnosis with is useful in understating the
evolution of illness and subsequently its treatment and outcome.

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Thank you