This document provides guidance on taking patient histories and conducting clinical examinations in an outpatient setting. It emphasizes the importance of listening to the patient's description of their problem, asking open-ended questions to obtain accurate details on symptoms, duration, character, location and other relevant history. Specific questions are suggested to efficiently obtain a patient's medical, surgical, medication and social histories to identify potential diagnoses and address the reason for their visit.

1. A Concise Practical Guide to
History taking and Workup
of Patients in OPD Based
Setting
DEPARTMENT OF COMMUNITY MEDICINE
GMCH 32 CHDANDIGARH
THE HEAD OF THE DEPARTMENT.: DR. N . K. GOYAL

2. LACK OF BOOKS /NOTES FOR QUICK AND CONCISE REVISION LEAD
TO THE FORMATION OF PDF . ALSO FOR FRESH LEARNERS WHO
WANT TO GO THROUGH ONLY IMPORTANT KEY CONCEPTS.
UNDER GUIDANCE OF HEAD OF THE DEPARTMENT DR N K GOEL ET
AL ( ALL RESPECTED FACULTY ) , I AM ABLE TO COMPILE
A SHORT E-BOOK, WHICH CAN BE BOTHE READ ONLINE AND
DOWNLOADED AS PDF.
DEPARTMENT OF COMMUNITY MEDICNE
GMCH 32
CHANDIGARH This Photo by Unknown author is licensed
under CC BY-SA.

3. History of Present Illness (HPI)
• Obtaining an accurate history
• MOST OF THE TIME YOU WILL be able to make a
diagnosis based on the HISTORY ALONE.
• TAKE THE TIME TO LISTEN TO YOUR PATIENTS
Successful interviewing is for the most part
dependent upon your already well developed
communication skills.
• DEVELOP COMMUNICATION SKILLS :
PRACTISING AND REVISING CLINICAL VIGNETS
YOU ARE COMFORTABLE WITH TO BEGIN WITH

4. Framework for Approaching Patient
This Photo by Unknown author is licensed under CC BY-SA.
DOCTOR-PATIENT

5. Framework for Approaching Patient
1. Initiate this process by describing a symptom that patient presents
with.
2. Additional questioning that will help to identify the root cause of the
problem.
3. HOLISTIC APPROACH
4. A list of questions grouped according to organ system and designed
to identify disease within that area. For example: For
Respiratory illnesses:
5. Do you have a cough?
6. If so, is it productive of sputum?
7. Do you feel short of breath when you walk?
8. Remember the relevant questions.

6. Initial Question(s):
1. Let the patient describe the problem in their own
words.
2. Open ended questions are a good way to get past the
block or diversion by patient without giving adequate
history.
3. These include:
• Initiation: "What brings your here? How can I help you?
• What seems to be the problem?"
• Push them to be as descriptive as possible.
• Focus on a single, dominant problem

7. • Any associated symptoms?
• What do they think the problem is and/or what are they worried it
might be?
• Why today?:
This is particularly relevant when a patient chooses to make mention
of symptoms/complaints that appear to be" long standing".
• Is there something new/different today ?
• Or like every other day when this problem has been present?
• Does this relate to a gradual worsening of the symptom itself?
• Has the patient developed a new perception of its relative importance (e.g. a
friend told them they should get it checked out)?
• Do they have a specific agenda for the patient-provider encounter?
CONCLUDING WHAT IS PURPOSE OF VISIT?

8. Follow-up Questions:
• Duration:
1. How long has this condition lasted?
2. Is it similar to a past problem?
3. If so, what was done at that time?

9. Severity/Character:
1. How bothersome is this problem?
2. Does it interfere with your daily activities?
3. Does it keep you up at night?
4. Try to have them objectively rate the problem.
5. If they are describing pain, ask them to rate it
from 1 to 10
6. Ask to describe the symptom in terms

10. Severity/Character:
• With which they are already familiar.
• AWhen describing pain, ask if it's like anything else that
they've felt in the past.
• Knife-like? A sensation of pressure? A toothache?
• If it affects their activity level, determine
to what degree this occurs. For example, if they complain
of shortness of breath with walking, ask for distance.
• How many stairs/floor ?
• How does this compare with 6 months ago?

11. Location/Radiation:
• Is the symptom (e.g. pain) located in a specific
place?
• Has this changed over time?
• Does it radiate to a specific area of the body?
• What makes it better (or worse)?
Pace of illness:
• Is the problem getting better, worse, or staying the
same?
• If it is changing, what has been the rate of change?

12. Past Medical History:
• Start by asking the patient if they have any medical problems.
• Have they ever received medical care?
• What problems/issues were addressed?
• Was the care continuous (i.e. provided on a regular basis by a single
person) or episodic?
• Have they ever undergone any procedures, X-Rays, CAT scans, MRIs or
other special testing?
• Ever been hospitalized?
• If so, for what?
• Prompt by the right questions!

13. Past Surgical History:
• Were they ever operated on, even as a child?
• What year did this occur?
• Were there any complications?
• If they don't know the name of the operation, try
to at least determine why it was performed.
Encourage them to be as specific as possible.

14. Medications:
• CURRENT MEDICATIONS IF ANY?
• If so, what is the DOSAGE?
• IS THE PATIENT AWARE WHY IS HE/SHE BEING TREATED?
• NON COMPLIANCE: MAKE
• ANY RELIABLE SOURCE OF REMINDER / HELP PATIENT MAKE A REMINDER OF
MEDICATION AND KEEPING A MANNUAL CAN ACTUALLY MAKE GREAT IMPROVEMENT
IN COMPLIANCE RATE.
• IS MEDICATION PURPOSE BEING DONE,
• FOR EXAMPLE IS HYPERTENSION OR DIABETES IN CONTROL WITH THE CURRENT
MEDICATIONS?.
• Over the counter or "non-traditional" medications. (traditional,ayurvedic,homeopathy
etc?
• How much are they taking and what are they treating? Has it been effective? Are these medicines
being prescribed by a practitioner? or Self administered?

15. CONFIDENTIAL HISTORY
• ALWAYS IN PRIVATE.
• SEXUAL ACTIVITY
• DRUG USE