How to go about the medical interview

1. Approach to History Taking
By Mabuku Sankombo

2. Outline
• Introduction
• The Calgary-Cambridge consultation guide
• Gathering the information.
• Guides on starting physical examination
• Explanation, planning and closing the Session

3. The Medical Interview
• History taking
Asking questions to obtain information and aid diagnosis
• It is gathering data both objective and subjective for the purpose
of:
 generating differential diagnosis
 Evaluating progress following specific treatment
 Evaluating change in the patients condition/impact of a specific disease
process.
• Its an art that one has to practice frequently
• It is estimated that 70-80% of diagnoses are based on history
taking alone.
(Kings College London 2013)

4. Calgary-Cambridge Consultation Guide
(Kurtz et al. 2005)
Closing the Session
Explanation and Planning
Physical Examination
Gathering Information
Initiating the Session
4
Providing
structure
Building
relationships

5. Initiating the Session
• Greet the patient
• Introduce yourself
• Get consent
• Ensure patient comfort and privacy
3 types of questions
OPEN
-Always start with an open ended
question
“How can I help you?”
CLOSED
-theses clarify and focus on the
concerns raised by the patient.
“Are you still vomiting?’
LEADING
-based on your assumptions that
leads the patient to the answer you
want to hear.
“You are not allergic to anything are
you?

6. Demographics
• Name
• Age
• Sex
• Address
• Ethnicity
• Occupation
• Religion
• Marital status.
• Date of Clerkship

7. Presenting Complaint
• The main reason why the patient is visiting the hospital.
• Use Open ended questions
• Complaints should be recorded in the patients own words
• Chronological order ( from oldest complaint, to the most recent ones)

8. History of presenting complaint
• Explore symptoms brought up in the presenting complaint, again in
chronological order, ask when the patient last felt well.
• Onset, Duration, Progress, periodicity, Aggravating factors, Relieving
Factors, Associated symptoms, severity.
• Exhaust all other symptoms of the system in question, highlighting
important positives and negatives.
• All risk factors of the possible diagnoses should be explored i.e.
Medical comorbidities, lifestyle factors.
• Previous Hospital admissions due to the same presenting ailments,
how it was treated.

9. Systemic Enquiry
• This is a guide not to miss anything
• Any significant finding should be moved to History of presenting
complaint.

10. General Cardiovascular GI Urinary Respiratory CNS MSK
•Weakness
•Fatigue
•Anorexia
•Change of
weight
•Fever/chills
•Lumps
•Night sweats
Chest pain
Paroxysmal
Nocturnal
Dyspnoea
Orthopnoea
Short Of
Breath(SOB)
Cough/sputum
(pinkish/frank
blood)
Swelling of
ankle(SOA)
Palpitations
Cyanosis
Appetite
(anorexia/weigh
t change)
Diet
Nausea/vomitin
g
Regurgitation/he
art
burn/flatulence
Difficulty in
swallowing
Abdominal
pain/distension
Change of bowel
habit
Haematemesis,
melaena,
haematochaezia
Jaundice
Frequency
Dysuria
Urgency/strangu
ry
Hesitancy
Terminal
dribbling
Nocturia
Back/loin pain
Incontinence
Character of
urine:color/
amount
(polyuria) &
timing
Fever
Cough(productiv
e/dry)
Sputum (colour,
amount, smell)
Haemoptysis
Chest pain
SOB/Dyspnoea
Tachypnoea
Hoarseness
Wheezing
Visual/Smell/Tas
te/Hearing/Spee
ch problem
Head ache
Fits/Faints/Black
outs/loss of
consciousness(L
OC)
Muscle
weakness/numb
ness/paralysis
Abnormal
sensation
Tremor
Change of
behaviour or
psyche.
Pariesis.
Pain – muscle,
bone, joint
Swelling
Weakness/move
ment
Deformities
Gait

11. Past Medical History
• Existing Medical conditions
• IHD/DM/Asthma/Hypertension/RHD, TB// Epilepsy :E.g. if diabetic- mention time
of diagnosis, current medication, clinic check up.
HIV Status.
• HIV: Viral load, CD4 count
• Previous hospitalizations
• Blood Transfusions
• Allergies
• Obstetric and Gynae history for female patients: Parity, LNMP

12. Drug History
• Any drugs or medication that the patient is currently on and their
doses.
• Use of alternative medicines i.e. Traditional /Herbal medicine &
alternative medicine.
• ART: what regimen the patient is on, if it has been ever changed,
reasons why it was changed.

13. Surgical history
• What type of operation.
• Indication
• Time and place
• Type of anaesthesia
• Complications

14. Family History
• Any familial diseases e.g. breast cancer, IHD, DM, schizophrenia,
Hypertension, asthma, albinism, haemoglobinopathies, Haemophilias
etc.
• Infections going around family as TB, Leprosy.
• Cholera, typhoid in case of epidemics.

15. Social History
• Smoking history - amount, duration & type. Calculate pack years
• Alcohol history - amount, duration & type.
• Travelling history
• Socioeconomic status
Home conditions as:
• Water supply.
• Type of house, number of inhabitants
• Sanitation status at home & surrounding.
• Animals / birds in his/her house.

16. Summarize History
• Name, Age,Sex, Presenting complaint, comorbidities. Important
positives and Important Negatives.
“This Mr X is a 27 year old male, RVD non reactive, presented with a 3
week history of a productive cough and a 1 week history of global
headaches. Only constitutional symptom he presented with is weight
loss. Patient was previously treated for pulmonary TB at age 5yrs and
has a 5 pack year history of smoking”
• Have a working diagnosis and well as differentials, that will help in
guiding your physical examination.

17. Physical Examination
• The third Calgary-Cambridge stage concerns physical
examination.
• Explanation of the procedure
• Consent sought
• Privacy and dignity maintained
• Chaperone (if required)
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18. Explanation, planning and closing the Session
• Ensuring appropriate point of closure:
• Explain and give information to the patient about the status quo and
the way forward ( investigations, treatment modalities etc).
• Summarise consultation briefly (with the patient), clarifying plan of
care.
• Final check that the patient agrees and is comfortable with the plan,
and asks for any corrections, questions and other items to discuss.
18

19. References
• Clinical Examination: a systemic guide to physical diagnosis. Talley and
O’Connor
• Kings College London (2013) Introduction to History Taking. [On-line].
http://www.kcl.ac.uk/health/study/facilities/chantler/docs/PatientEd
ucation/HistoryTakingNOTES.doc [Accessed 15 June 2017].
• Kumar and Clark

20. Thank You