Clinical Method - Patient history taking procedures

Presented By
Prof Sriram Chandra Mishra
Kayachikitsa Department
VYDS Ayurved Mahavidyalaya, Khurja
Patient
History taking procedures

C. V. 4/12
KNOWLEDGE & WISDOM
→ Over 80% of diagnoses are made on history alone, a
further 5-10% on examination and the remainder on
investigation.
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2

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3
CLINICAL METHOD –
It is the term used to describe a properly organized approach to the
patient and to his/her disease.
CLINICAL –
Founded on actual observation and treatment of patients as distinguished
from data obtained by experimentation or pathology.

4 11/28/2021
It is truisms that “DIAGNOSIS SHOULD PRECEDE TREATMENT WHENEVER
POSSIBLE”, but the wise doctor always strive not simply to be a diagnostician but
rather someone who elucidates human problems. (Hutchinson’s clinical method)
C. Su. 20/20
• For example,
→ an ambulance paramedic would typically limit his history to important details, such as name, history of presenting complaint, allergies, etc.
→ In contrast, a psychiatric history is frequently lengthy and in depth, as many details about the patient's life are relevant to formulating a
management plan for a psychiatric illness.

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But if diagnosis is not possible, then treat according to nature of the
disorder, locations, etiological factors etc.
C. Su. 18/44-47

6 11/28/2021
• TRIVIDHA - DARSAN, SPARSAN, PRASNA (A.H.SU.1/22)(C.CHI.25/22)
APTOPRADESH, PRATAKSHA, ANUMAN (C.VI.4/3)
• CHATURVIDHA - APTOPADESH, PRATAKSHA, ANUMAN, YUKTI (C.SU. 11/17)
• PANCHAVIDHA – NIDAN, PURVARUPA, RUPA, UPASAYA, SAMPRAPTI (M.N.)
• SADVIDHA – SROTENDRIYA, TWACHA, NETRA, JIHWA, GHRANA
(PANCHABHI SROTADIBHI) AND PRASNA PARIKSHA
• ASTAVIDHA – NADI, MUTRA, MALA, JIHWA, SABDA, SPARSA, DRUK, AKRITI (YOGA RATNAKAR)
• DASAVIDHA – PRAKRITI, VIKRITI, SARA, SAMHANAN,
PRAMANA, SATMYA, SATWA, AHARA SAKTI,
VYAYAMA SAKTI, VAYAH (Charak)

7 11/28/2021
SYSTEMIC
EXAMINATIONS
GENERAL
EXAMINATIONS
PERSONAL DETAILS
DIAGNOSIS
&
TREATMENT
THE HISTORY
PHYSICAL & MENTAL
EXAMINATIONS
PROVISIONAL
DIAGNOSIS
------------------
INVESTIGATIONS

8 11/28/2021
PRINCIPLES OF CLINICAL METHOD
• Properly organized approach (NO PROPER SEQUENCE)
The experienced doctor begins the consultation from the moment the patient walks into
the room, the general appearance, dress, attitude, gait, vocabulary, personality and only
finished when the patient has left.
• Patient – Doctor Relationship
Vocal tones, body language, openness, presence and concealment of attitude, maintain
a professional rapport, uphold patients’ dignity and respect their privacy etc are responsible
for a satisfactory establishment of Patient – Doctor relationship .
• Information
Information regarding illness should always be obtained from the patient himself,
whenever the patient is in a fit state to communicate. In case of patient’s consciousness is
disturbed or he/she is critically ill or mentally infirm, such information may be collected from
a relative, who has been observing the patient during most part of his illness.

9 11/28/2021
Cont. PRINCIPLES OF CLINICAL METHOD
• Properly organized approach (NO PROPER SEQUENCE)
The experienced doctor begins the consultation from the moment the patient walks into
the room, the general appearance, dress, attitude, gait, vocabulary, personality and only
finished when the patient has left.
• Patient – Doctor Relationship
Vocal tones, body language, openness, presence and concealment of attitude, maintain
a professional rapport, uphold patients’ dignity and respect their privacy etc are responsible
for a satisfactory establishment of Patient – Doctor relationship .
• Information
Information regarding illness should always be obtained from the patient himself,
whenever the patient is in a fit state to communicate. In case of patient’s consciousness is
disturbed or he/she is critically ill or mentally infirm, such information may be collected from
a relative, who has been observing the patient during most part of his illness.

10 11/28/2021
MEDICAL RECORDS
Personal health records (P.H.R.)
A chronological written account of individual patient's examination and treatment is known as that
individual patient’s medical record.
The medical record includes a variety of types of "notes" entered over time by health care professionals.
This includes
 Admission notes (Bio-data, History, physical findings etc)
 Diagnostic test results (Pathology, x-rays, ECG, USG etc)
 Diagnosis
 Medications and therapeutic procedure notes (Preoperative, Operative, postoperative, delivery notes,
postpartum notes etc
 Progress notes of observations and medications
 Discharge notes
Information in medical records is sensitive as Personal information covered by expectations of privacy, so
many ethical and legal issues are implicated in their maintenance.

CLINICAL METHODS
Personal details

PERSONAL DETAILS
(BIODATA)
1. NAME
2. AGE
3. SEX
4. ADDRESS
5. RELIGION & CASTE
6. MARITAL STATUS
7. OCCUPATION

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• NAME
Name & Surname has to be correctly recorded for easy identification. This has also
additional importance for medico legal cases (MLC) and insurance purposes.
• AGE
Some diseases occurring commonly in one extreme of the age and are rare in the other
extreme. For example-
Childhood - Rheumatic fever, Measles, Diphtheria
Middle age - Chronic Myelocytic Leukemia, Peptic ulcer
Old age – Malignancies, Ischemic heart disease
• SEX
Some diseases are found in a particular sex. For example – Hemophilia occurs exclusively
in males and Primary pulmonary hypertension and systemic lupus erythematous are
commonly seen in females.

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• ADDRESS
Address is required for record and future correspondence, besides certain diseases are
common in certain localities. Endemic goiter being commonly found in mountainous areas and
filariasis in the costal regions.
The address must written accurately in detail Like
→ C/O (S/O, D/O, W/O)
→ A.T., P.O., P.S., DIST., PHONE ETC.
(P.S. / Police station must be there as deal with medico legal cases /MLC)
→ Also Entry the name and address of the person who brought the patient to hospital.
• RELIGION & CASTE
Sickle cell anemia is seen in a special caste of peoples. Carcinoma of penis is extremely
rare in Muslims because of the practice of circumcision during childhood; whereas it is high in
all other religious groups where such practice is not adopted.

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• MARITAL STATUS
Hemophilia is transmitted by females to males. Diseases having homozygous recessive
heritance are greatly influenced by genotype of the couple.
• OCCUPATION
Occupation has a great bearing in the causation of some diseases known as occupational
hazards or occupational diseases.
For example – People exposed to radiation are more prone to cancer whereas
Pneumoconiosis is common among the mine workers. In case of child write parent’s
occupation.

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SYSTEMIC
EXAMINATIONS
GENERAL
EXAMINATIONS
PERSONAL DETAILS
DIAGNOSIS
&
TREATMENT
THE HISTORY
PHYSICAL & MENTAL
EXAMINATIONS
PROVISIONAL
DIAGNOSIS
------------------
INVESTIGATIONS

11/28/2021
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DEFINITION OF MEDICAL HISTORY
It is the record of medical events that have already taken place in the patient.
History taking is an art, which a doctor learns over the years by repeated practice and experience.
PRINCIPLES OF HISTORY TAKING
Put the patient in ease, choose an appropriate setting.
Start by eliciting the presenting complaint
Encourage the patient to give an uninterrupted history.
Use language the patient understands.
Avoid suggesting symptoms or answers to the patient.
Write notes while the patient is talking.
Use selective questions to clarify the presenting history.
Use further questions of diagnostic relevance.
Ask cardinal questions which reviewing the systems.

COMPONENTS OF THE
HISTORY TAKING
1. Chief Complaint(S)
2. Present History / History Of Present Illness
3. Past History / History Of Past Illness
4. Family History
5. Personal History (Socio-economical-occupational history)
6. Treatment History / Drug History
7. Obstetric & gynecological history
8. Sexual history
9. Psychiatric history etc

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CHIEF COMPLAINT (S)
The main complaint which made the patient to visit to the doctor. Some patients
have more than one complaints.
Principles
 This should be recorded using the patient's word, rather than medical terms like
→ Chest pain on walking uphill should not be translated into angina of effort which
may bias the critical evaluation.
 This should be noted in clear chronological order with duration (if available) i.e. If
patient explain with duration, then write it here. Otherwise don’t disturb in middle.
 Leading questions should not be asked at this stage of history taking.
Abbreviations - CC/Presenting Complaint (PC)/Reason for Encounter (RFE)/Presenting
Problem/Problem on admission/Reason for Presenting

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PRESENT HISTORY / HISTORY OF PRESENT ILLNESS
This part of the history taking refers to a detailed analysis of symptoms. Once the
patient has had time to communicate their presenting complaint, then begin to explore the
issue with further open and closed questions.
Principles
Ask the patient to tell the story of his / her illness from the beginning like onset, progress
etc.
Leading questions may have to be asked in order to elicit adequate information but not
unnecessary leading questions because a positive reply is of limited diagnostic value.
Replies in negative should also be taken into consideration.
Different sources include different questions to be asked while conducting an Present
History.
Abbreviations - History Of Present Illness (HPI) (H/O present illness) / History Of Presenting
Complaint (HPC) / Present History / Case Of (C/O)

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Present History may divided into three parts
for easy elaboration -
1. GENERAL INTERROGATION
2. SYMPTOMS ANALYSIS
3. SYSTEMIC INTERROGATION

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General Interrogations
1. When was he / she apparently well ? (When did the symptom
start?) ...... (DURATION)
2. How was the onset of the illness – Acute / Gradual / Insidious…….
3. In what chronological order the symptoms appeared……..
4. How have the symptoms progressed / modified during the course of
illness…
5. Whether any treatment has been received & if so what have been
the result of such treatment.............

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Example- 1
The patient was apparently well before 3 days. Suddenly chill & rigor started.
After some times temperature rises highly. Then all subsided automatically with profuse
sweating. Today similar symptoms rises again with headache and vomiting. Patient
taking some medicines but not relieved.
Example - 2
Week before the admission, the patient fell while gardening and cut his foot
with a stone. By that evening, the foot became swollen and patient was unable to walk.
Next day patient attended Merjan hospital and they gave him some oral antibiotics.
He doesn’t know the name. There is no effect on his condition and two days prior to
admission, the foot continued to swell and started to discharge pus. There is high fever
and rigors with nausea and vomiting.

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OPQRST
O - Onset
P - Provoking and palliating factors
Q - Quality ("What does it feel like?")
R - Radiating (noting location of origin)
S - Severity (usually use a scale from 0-10)
T - Timing (constant, intermittent, duration, time of day)
SOCRATES
S - Site
O - Onset
C - Characteristics
R - Radiating
A - Alleviating
T - Timing
E - Exacerbating factors
S - Severity
SYMPTOMS ANALYSIS
Each symptom should analyzed vividly. Example – Pain/ Headache/ Breathlessness /
Tiredness etc
OLD CARTS
• O - Onset
• L - Location/Radiation
• D - Duration
• C - Characteristics
• A - Aggravating or alleviating factors
• R - Reliving factors
• T - Timing
• S - Severity

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(OLD CARTS - Onset, Location/radiation, Duration, Character, Aggravating factors, Reliving
factors, Timing and Severity)
• Onset:
 When did the symptom start? Was the onset acute or gradual or Insidious ?
Example – Acute onset – fever , Gradual onset – Sciatica, Insidious – T.B.
• Location/radiation
 Where is the exact location point of symptom ?
 Does the pain radiate anywhere?
Example - Shoulder tip pain can occur in ectopic pregnancy
Angina pain often spreads to neck, throat, lower jaw, teeth or shoulders and arms.
• Duration:
 How long did the symptom last? (e.g. minutes, hours, days, weeks, months, years)

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• Character
 What is the character of symptom ?
 Intermittent or continuous:
 Is the symptom always present or does it come and go?
 If intermittent, how frequent is the symptom?
Example - Is the pain sharp or a dull ache? Is the pain intermittent or continuous?
Is the fever regular or irregular?
• Aggravating / Precipitating factors:
 Are there any obvious triggers for the symptom?
Example – NSAIDs aggravates gastric pain. Workload precipitate stress.
• Relieving factors:
 Does anything appear to improve the symptoms?
Example – Gastritis not relieved by Antacids but relived by Sorbitrates is cardiac origin.

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• Timing
 constant, intermittent, duration, time of day
Example - What is the overall time course of the pain? (e.g. worsening, improving,
fluctuating)
• Severity:
 How severe does the patient feel the symptom is?
 Is it impacting significantly on their day to day life?
Example - On a VAS scale of 0-10, how severe is the pain, if 0 is no pain and 10 is
the worst pain you’ve ever experienced.

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Several acronyms have been developed to categorize the appropriate questions to include.
(http://en.wikipedia.org/wiki/History_of_the_present_illness)
CMS
(Centres for
Medicare and
Medicaid Services)
"OPQRST"
or "PQRST"
"CLEARAST" "LIQOR AAA“
"SCHOLAR"
("S" = Symptoms)
"COLDER AS"
Location
"R": Region and
Radiation
"L": Location "L": Location "L:" Location "L:" Location
Quality
"Q": Quality of the
pain
"C": Character "Q": Quality "C:" Characteristics "C": Character
"R": Radiation "R": Radiation see above "R": Radiation
Severity "S": Severity "S": Severity "I": Intensity see above "S": Severity
Duration "O": Onset "T": Time frame "O": Onset
"O:" Onset
"H:" History
"D:" Duration
Timing "T": Time see above see above see above "O": Onset
Context
Modifying factors
"P": Provocation or
Palliation
"E": Exacerbation
"A": Aggravating
factors
"A:" Aggravating
factors
"E:" Exacerbation
"A": Alleviation
"A": Alleviating
factors
"R:" Remitting
factors
"R:" Remitting
factors
Associated signs &
symptoms
"A": associated
symptoms
"A": Associated
symptoms
see above
"A": Associated
symptoms

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SYSTEMIC REVIEW {Review of systems/ Direct questions}
• It is a technique used by health-care providers for eliciting a history from a patient
which have been forgotten or dismissed by the patient as unimportant or for a
verity of emotional reasons including embarrassment, anxiety or guilt.
Principles
• It is not necessary to ask every patient all systemic interrogations. However while
learning to take a history (students), it is useful to go through a full checklist.
• The negative values also have important role in diagnosis. In a negative response,
write “ROS –All other systems were reviewed and are negative”.
• If a positive response is elicited then more detailed questions (OLD CARTS - Onset,
Location/radiation, Duration, Character, Aggrevating factors, Reliving factors,
Timing and Severity) may be required.
Abbreviations – ROS / Review of systems / systems enquiry / systems interrogation

CARDINAL SYMPTOMS OF SYSTEMIC INTERROGATION
System Examples
General
(CONSTITUTIONAL)
SYMPTOMS
• Unexplained Weight Loss/Change Of Weight
• Night Sweats
• Fatigue/Malaise/Lethargy/Weakness
• Sleeping Pattern
• Appetite/Anorexia
• Fever
• Itch/Rash
• Recent Trauma
• Lumps/Bumps/Masses
• Unexplained Falls

System Examples
C
A
R
D
I
O
V
A
S
C
U
L
A
R
S
Y
S
T
E
M
 Chest (Precordial) Pain / Tightness- Origin & Radiation, Character,
Duration, Relieving & Aggravating Factors
 Shortness of Breath (Dyspnoea) On Exertion / Rest
 Exercise intolerance
 Breathlessness When Lying Flat (Orthopnoea)
 Attacks Of Nocturnal Breathlessness (Paroxysmal Nocturnal Dyspnoea / PND)
 Ankle Swelling / Edema
 Palpitations
 Faintness
 loss of consciousness
 Pain In Legs On Exertion (Claudication)
 History Of Cough/Expectoration/Haemoptysis (pinkish/frank blood)
 Digestive Disturbances
 Cyanosis

System Examples
R
E
S
P
I
R
A
T
O
R
Y
S
Y
S
T
E
M
• Cough (Dry/Productive) - Relation With Posture & Time
• Sputum Quantity – Scanty/Profuse, Odour,
Character – Mucoid / Mucopurulent / Purulent
Relation With Posture & Time
• Presence Of Wheezing/Strider
• Shortness Of Breath : Exercise Tolerance
 Precordial (Chest) Pain / Tightness- Origin & Radiation, Character,
Duration, Relieving & Aggravating Factors
• Tachypnoea
• Hoarseness
• Haemoptysis

System Examples
ALIMENTARY
SYSTEM
(Gastrointestinal)
• Abdominal Pain - Character & Time Of Pain - Site & Radiation -
Periodicity - Relation With Food / Alkali / Vomiting -.......
• Diet / Appetite (anorexia/weight change).......
• Heart Burn / Regurgitation - Acid Eructation / Water Brash / Indigestion /
Bloating, Cramping / Anorexia / Food Avoidance
• Change In Bowel Habit (Diarrhea / Constipation / Mucus Mixed / Dry Heaves Of The
Bowels (Tenesmus)
• Nausea / Vomiting (Frequency & Characteristics Of Vomited Matter) / Vomiting
Blood (Haematemasis)
• Colour Of Motion (Pale / Dark Black Tarry Stools (Malaena) / Fresh Blood (Bright
Red Blood Per Rectum - BRBPR, Hematochezia)
• Flatulence - Foul Smelling / Inability To Pass Gas (Obstipation)
• Jaundice (Colour & Itching)

System Examples
U
R
I
N
A
R
Y
S
Y
S
T
E
M
Micturition – Irritative vs.. Obstructive symptoms
 Incontinence,
 Pain / Burning Sensation On Passing Urine (dysuria)
 Haematuria
 Nocturia
 Frequency Of Passing Urine (polyuria)
 Difficulty In Starting To Pass Urine (hesitancy)
 terminal dribbling
 decreased force of stream
 Abnormal Colour Of Urine (Blood Etc)

System Examples
G
E
N
I
T
A
L
S
Y
S
T
E
M
Male
• Mental Attitude To Sex
• Morning Erections
• Frequency Of Intercourse
• Ability To Maintain Erections
• Ejaculations
• Urethral Discharge
Female – (If Premenopausal)
• Age Of Onset Of Periods (Menarche)
• Regularities Of Periods (E.g. 28 Day)
• Length Of Periods
• Losing More Or Less Blood Than Usual
• Premature Tension / Pain At Periods
• Use Of Contraception
• Presence Of Vaginal Discharge
Female – (If Post Menopausal)
• Bleeding
• Stress And / Or Urge Incontinence
• Libido
• Pain During Intercourse (Dyspareunia)
Breast
• Pain, soreness, lumps, or discharge.

System Examples
N
E
R
V
O
U
S
S
Y
S
T
E
M
• Special Senses - Any Changes In Sight (Visual), Smell, Hearing And Taste
• Seizures, Faints, Fits, Black outs, loss of consciousness(LOC)
• Funny Turns
• Headache
• Pins And Needles (Paraesthesiae) Or Numbness / Abnormal sensation
• Limb Weakness / Paralysis
• Poor Balance
• Speech Problems
• Sphincter Disturbance
• Higher Mental Function And Psychiatric Symptoms, Change of behaviour
• Sleep Patterns
• Tremor

System Examples
MUSCULO
SKELETAL
SYSTEM
(LOCOMOTOR
SYSTEM)
• Pain (muscle, bone, joint)
• Misalignment (Deformities)
• Stiffness (morning vs. day long; improves/worsens with
activity)
• Joint swelling
• Decreased range of motion (ROM)
• Crepitus
• Functional deficit (Weakness/movement)
• Arthritis

System Examples
INTEGUMENTARY
SYSTEM
(SKIN)
• Pruritus
• Rashes
• Stria
• Lesions
• Wounds
• Incisions
• Acanthosis Nigricans
• Nodules
• Tumors
• Eczema
• Excessive Dryness And/Or Discoloration

System Examples
Eyes
• Visual changes
• Headache
• Eye pain
• Double vision
• Scotomas (blind spots)
• Floaters or "feeling like a curtain got pulled down"
(retinal haemorrhage vs. Amaurosis fugax)

System Examples
MOUTH AND EAR,
NOSE, THROAT
(ENT)
• Runny Nose
• Frequent Nose Bleeds
(Epistaxis)
• Sinus Pain
• Stuffy Ears
• Ear Pain
• Ringing In Ears (Tinnitus)
• Gingival Bleeding
• Toothache
• Sore Throat
• Condition Of Mouth (Infected Tongue
/ Bleeding Gums)
• Pain With Swallowing (Odynophagia)
• Difficulty With Swallowing
(Dysphagia) (Solids Vs. Liquids)
• Increased Thirst…
• Increased Salivation…
• Disorders Of Taste.....

System Examples
Psychiatric
• Depression
• Sleep Patterns
• Anxiety
• Difficult Concentrating
• Body Image
• Work And School Performance
• Paranoia
• Ahedonia
• Lack Of Energy
• Episodes Of Mania
• Episodic Change In Personality
• Expansive Personality
• Sexual Or Financial 'Binges’

System Examples
Endocrine
SYSTEM
• Hyperthyroid: prefer cold weather, mood swings, sweaty, diarrhoea, oligomenorrhoea, weight
loss despite increased appetite, tremor, palpitations, visual disturbances
• Hypothyroid - prefer hot weather, slow, tired, depressed, thin hair, croaky voice, heavy
periods, constipation, dry skin
• Diabetes: polydipsia, polyuria, polyphagia (constant hunger without weight gain is more typical
for a type I diabetic than type II)
• Hypoglycemia - dizziness, sweating, headache, hunger, tongue dysarticulation
• Adrenal: difficult to treat hypertension, chronic low blood pressure, orthostatic symptoms,
darkening of skin in non-sun exposed places
• Reproductive (female): menarche, cycle duration and frequency, vaginal bleeding irregularities,
use of birth control pills
• Reproductive (male): difficulty with erection or sexual arousal, depression, lack of
stamina/energy

System Examples
Hematologic
/
lymphatic
SYSTEM
• Anemia
• Purpura
• Petechia
• Results From Routine Hemolytic Diseases Screening
• Prolonged Or Excessive Bleeding After Dental Extraction / Injury
• Use Of Anticoagulant And Antiplatelet Drugs (Including Aspirin)
• Family History Of Hemophilia
• History Of A Blood Transfusion
• Refused For Blood Donation
• "Difficulty Breathing" Or "Choking" (Anaphylaxis) As A Result Of Exposure To Anything (And
State What; E.G. "Bee Sting“)
• Swelling Or Pain At Groin(s), Axilla(e) Or Neck (Swollen Lymph Nodes/Glands)
• Allergic Response (Rash/Itch) To Materials, Foods, Animals (E.G. Cats), Reaction To Bee Sting
• Unusual Sneezing (In Response To What), Runny Nose Or Itchy/Teary Eyes;
• Food, Medication Or Environmental Allergy Test(s) Results.

System Examples
Allergic / Immunologic
• "Difficulty Breathing" Or "Choking" (Anaphylaxis) As A Result Of Exposure
To Anything (And State What; E.G. "Bee Sting“)
• Swelling Or Pain At Groin(s), Axilla(e) Or Neck (Swollen Lymph
Nodes/Glands)
• Allergic Response (Rash/Itch) To Materials, Foods, Animals (E.G. Cats),
Reaction To Bee Sting
• Unusual Sneezing (In Response To What), Runny Nose Or Itchy/Teary
Eyes;
• Food, Medication Or Environmental Allergy Test(s) Results.

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PAST HISTORY (History of past illness)
A past medical history is the total sum of a patient's health status prior to
the presenting problem i.e. "the patient's past experiences with illnesses, operations,
injuries and treatments“.
Principles
• The term Hospitalizations includes all medical, surgical and psychiatric
hospitalizations.
• Note the date, reason, duration for the hospitalization.
Abbreviations – History of past illness / Past Medical History / PMH

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While conducting a PMH, different questions to be asked. They include
Similar Symptoms In The Past (Conditions That May Recur)
Ex – Peptic Ulcer, Asthma, Allergy
Prolonged Illness In The Past (Chronic Conditions)-
Ex – Diabetes, Heart Disease, Epilepsy, hypertension, cancer
Serious Illness In The Past (Conditions That May Give Rise To Long Term Complications)-
Ex – Jaundice leads to Cirrhosis Of Liver, Diabetes, Hypertension leads to Ischemic Heart
Disease.
Surgical History & any Complications
Note the type of procedure, date, hospital, surgeon, any complications and follow up
arrangements. Note the type and date of injury or accidents.
(In females) Obstetric & Gynecological History & any Complications-
Total number of pregnancies, whether they are full term, preterm, miscarriages, abortions,
living, as well as any complications. This include menopause and date. Include sexual history
and any history of sexually transmitted diseases.

Birth history:
Details of labour and delivery of patient, admission to NICU, maternal fever, duration of
rupture of membranes, APGAR scores (particularly import in first three months of life)
Growth and development:
Plots of height, weight, and head circumference are standard content for paediatric records,
any change in trajectory (e.g. growth plots which cross percentile lines rather than running
parallel), developmental mile stones, any IQ or other developmental testing
Allergies -
Note any environmental, food, latex or drug allergies, as well as the specific type of reaction,
e.g. anaphylaxis, rash, itching.
Immunizations –
Take a careful record of all immunizations, including tetanus, diphtheria, pertussis, polio,
Hepatitis B, measles, mumps, rubella, etc
Other Sources Of Information
Previous Medical Records / Radiographs Etc

FAMILY HISTORY
A family history consists of information about disorders from which the direct blood
relatives of the patient have suffered.
Principles
How many children & siblings are in the family?
All close relatives (parents/sibs/children) alive-
If not, what was the cause of death & age of death?
If alive, do they have any significant illness or are they on known medications
Is there A family history of any relevant specific conditions (ex – diabetes, hypertension,
thyroid disease etc)
In complex situations, a family tree or genogram may be used to organize the resulting
information.
Abbreviations –FH

FAMILY TREE
OR
GENOGRAM
Term Definition
First cousin • The children of two siblings.
Second cousin • The children of two first cousins.
Third cousin • The children of two second cousins.
First cousin once removed • Two people for whom a first cousin relationship is one generation removed.
First cousin twice removed • Two people for whom a first cousin relationship is two generations removed.
Second cousin once removed • Two people for whom a second cousin relationship is one generation removed.

Example of some genetically transmitted diseases
 X-Linked recessive diseases
• Ex. – Duchene muscular dystrophy, Hemophilia, G6PD deficiency, etc)
Women are carriers and do not suffer from the disease where as males suffer from the
disease. Hence in such illnesses, the family history would suggest similar illness in the patient’s brothers,
sister’s sons, mother’s brother, mother’s brother’s sons.
 Autosomal dominant disorders
• Ex. – Familial Hyperlipidemias, Polycystic Kidneys, Neurofibromatosis etc)
There will be a family history of similar illness in either of the parents and/or Grandparents.
 Autosomal recessive disorders
• Ex. – Sickle cell anemia, Thalassemia etc)
There is usually no history of similar illness in the parents since they may be heterozygous
and hence only carriers. However history of consanguineous marriage in the parents (marriage between
cousins or brothers & sister or uncle or niece) may be present and may be responsible for the
homozygous state in the patient and thus the manifestation of the disease.

Difficulties
Family histories may be imprecise because of various possible reasons:
• Adoption, fostering (bring up), illegitimacy (not law fully married) and adultery (voluntary sexual contact between
married person with other)
• Lack of contact between close relatives
• Uncertainty about the relative's exact diagnosis
• Some medical conditions are carried only by the female line, and tracing female
ancestors can be difficult in societies that change the woman's family name when she
marries.
• Other medical conditions are carried only by the male line. Tracing male ancestors
may be impossible if the conception is due to rape or sexual activity outside of a
marriage.
fostering (bring up),
illegitimacy (not law fully married)
adultery (voluntary sexual contact between married person with other)

Personal History
(Socio-Economic Occupational History)

PERSONAL HISTORY
(SOCIO-ECONOMIC OCCUPATIONAL HISTORY)
Personal history is a portion of the Admission note addressing familial,
occupational and recreational (activity of leisure) aspects of the patient's personal life
that have the potential to be clinically significant.
An individuals adaption to his occupational and social environment may
profound repercussion on his health. It may help not only in relation to diagnosis but
also in the planning of rehabilitation.
Abbreviations – SocHx / Socio-Economic Occupational History

58 11/28/2021
When taking history it is useful to enquiry about the followings.
SOCIAL LIFE
• Home surroundings
• Amount & quantity of sleep
• Personal interest & Habits
• Domestic & Marital relationship
• Travel
• Prison etc.
ECONOMICAL CONDITION
OCCUPATIONAL HISTORY

SOCIAL LIFE
 HOME SURROUNDINGS:- It may be helpful to know about the detail’s of patient’s home &
it’s surroundings including living arrangements. For example -
• Sanitary conditions (? - infection)
• The possible existence of overcrowding (? - T.B.)
• Loneliness (? - Depression)
• Number of steps leading up to the room or bed room (? - Angina, Chronic bronchitis, R.A.) etc.
 AMOUNT & QUANTITY OF SLEEP:- Does the patient take hypnotics to sleep? Sleep
disturbances are common in anxiety states and many psychoses. A useful mnemonic for sleep
patterns is BEARS,
• Bedtime problems (e.g. snoring, sleep apnea, or nightmares)
• Excessive daytime sleepiness
• Awakenings at night
• Regularity and duration of sleep
• Snoring

 PERSONAL INTEREST & HABITS :-
• Appetite & Food Habits
• Bowel & Micturition Habits
• Addictions
• Diet & Other Beverages
• Sexual Activity
 Appetite & Food Habits -Loss of appetite and weight may suggest an active disease process.
 Bowel & Micturition Habits - This also important in disease process like diabetes, IBS etc.
 Addictions – The type, amount, duration as well as any past treatment or drug
rehabilitation on addictions are to be noted.
Examples of addictions
 Alcohol
 Smoking
 Tobacco chewing (pack years)
 Illicit Drugs/Recreational drug use (Charas, Ganja, Marijuana, Drug abuse etc)

61 11/28/2021
 Diet & Other Beverages –
→ Type of diet may have important implication in relation to nutritional problems, psychological
instability and lung diseases. Ask about everything the patient has eaten the day before and
for the past week. Note the type of food consumed and do a nutritional status assessment.
→ Patient’s leisure pursuits allows a better appreciation of the patient’s life style like joining party
etc. This may expose to environmental pathogens through recreational activities or pets.
For example –
• Excess use of wine in party - The regular consumption of more than 21 units of alcohol per week in
males or 14 units in females, confers a significant risk of developing an alcohol related disorder. These
include chronic liver disease, peripheral neuropathy, cerebral atrophy, pancreatitis, and alcoholic
cardiomyopathy. There is also a liability to develop hypertension.
• Amenorrhoea is common in young women who take a lot of physical activity.
 Sexual Activity: This is an uncomfortable line of questioning for many practitioners. However, it can
provide important information and should be pursued as there is increased risk of various infections among
prostitutes, johns and males engaging in anal-receptive intercourse.

 DOMESTIC & MARITAL RELATIONSHIP :- It is of great important in psychoneurosis. His
feelings about other members of his family and relatives and the opinion of other
members about him are to be carefully recorded.
 RESIDENCE / TRAVEL OTHER PLACES :- By Recent foreign travel Infection may be
transmitted to an area, where it is not normally encountered. Ex – COVID 19, EBOLA,
SARS etc.
 PRISON- Especially if tuberculosis needs to be ruled out.
ECONOMICAL CONDITION
 Upper class
 Upper middle class
 Lower middle class
 Poor class
A person’s social class has a significant impact on their physical health, their ability to receive
adequate medical care and nutrition, and levels of health insurance etc. Social determinants can
be used to predict one’s risk of contracting a disease or sustaining an injury etc.

OCCUPATIONAL HISTORY
The relevant aspects of Occupational history include compensation for an
occupational related illness/accident or the receipt of a pension/invalidity benefit.
Example:-
• Mining industries - Silica dust - Silicosis of the lungs
- Asbestos fiber - Asbestosis of lungs
• Exposure to dust of mouldy hay - Farmer’s lung from
It is necessary to know the exact nature of his present work & previous work,
hours of work, the place of work and whether it exposes him to injurious influences.

Questions related to occupational history
• Ask about his attitude to his wok, his employers, his workmates and the possibility of financial
worries.
• Is the job dusty and if so what tools make the dust ?
• Are there fumes or vapors and if so what are the chemical substances involved ? (most of the
toxic substances encountered in dangerous trades enter the body by inhalation, although some
solvents penetrate the skin).
• Is hood installed over the bench and is it connected to a suction system ?
• Is protective clothing provided ?
• Is a special suit or goggles required and why ?
• Has any similar illness affected a fellow employee ? (certain occupational hazards are associated
with office works, for example – repetitive strain injury and migraine induced by stress or
inappropriate lighting. )

Drug History
(Treatment History)

DRUG HISTORY (TREATMENT HISTORY)
Treatment History is a portion of the admission note essential to obtain full detail of all
the drugs and medicines (including AYUSH, Alternative therapies e.g. acupuncture, massage,
herbal medicine, vitamins, chiropractice and laxatives etc) taken by the patient.
Principles
• Check all previous prescriptions at this stage. (Not before this stage, because wrong diagnosis
may biased)
• Ask about known drug allergies or suspected drug reactions. Record this information in such a
way on the front of the notes that it is obvious to any doctor seeing the patient.
• Note whether concerning medication prescribed or self administered, taking the medications
according to the prescribed instructions., whether taken regularly or at whim and if there has
been recent sudden increase or reduction in the dosage.
• Direct questions should be asked about name, dosage, frequency of any medication, including
any over-the-counter medications.

67 11/28/2021
Abbrev. Meaning
Latin (or New
Latin) origin
a.c. before meals ante cibum
a.d., ad, AD right ear auris dextra
a.m., am, AM morning ante meridiem
a.s., as, AS left ear auris sinistra
a.u., au, AU
both ears together or each
ear
aures unitas or auris
uterque
b.d.s, bds, BDS 2 times a day bis die sumendum
b.i.d., bid, bd
twice a day / twice daily / 2
times daily
bis in die
gtt., gtts drop(s) gutta(e)
h., h hour hora
h.s., hs at bedtime or half strength hora somni
ii two tablets duos doses
iii three tablets trēs doses
n.p.o., npo, NPO
nothing by mouth / not
by oral administration
nil per os
nocte every night Omne Nocte
o.d., od, OD
once a day
right eye
omne in die
oculus dexter
o.s., os, OS left eye oculus sinister
o.u., ou, OU both eyes oculus uterque
p.c. after food post cibum
p.m., pm, PM afternoon or evening post meridiem
p.o., po, PO
orally / by mouth / oral
administration
per os / nonstandard
form per orem
p.r., pr, PR rectally per rectum
p.r.n., prn, PRN
as needed, (also Pertactin -
a key antigen of ac.Pertussis
vaccine)
pro re nata
Abbrev. Meaning
Latin (or New
Latin) origin
q. every quaque
q.1.d., q1d every day quaque die
q.1.h., q1h every hour quaque hora
q.2.h., q2h every 2 hours quaque secunda hora
q.4.h., q4h every 4 hours quaque quarta hora
q.6.h., q6h every 6 hours quaque sexta hora
q.8.h., q8h every 8 hours quaque octava hora
q.a.m., qAM, qam every morning quaque ante meridiem
q.d., qd every day / daily quaque die
q.d.s, qds, QDS 4 times a day quater die sumendum
q.h., qh every hour, hourly quaque hora
q.h.s., qhs every night at bedtime quaque hora somni
q.i.d, qid 4 times a day quater in die
q.o.d., qod
every other day /
alternate days
quaque altera die
q.p.m., qPM, qpm
every afternoon or even
ing
quaque post meridiem
q.s., qs
a sufficient quantity
(enough)
quantum sufficiat
q.wk. also qw weekly (once a week)
Rx, Rx, ℞ prescription recipe
Sig., S. directions signa
Stat.
immediately, with no
delay, now
statim
t.d.s, tds, TDS 3 times a day ter die sumendum
u.d., ud as directed ut dictum

Obstetric & Gynecological History

OBSTETRIC & GYNECOLOGICAL HISTORY
Menstrual history Obstetric History
• Age at menarche
• Last menstrual period
• Duration / Frequency
• Menstrual blood flow - light / heavy
• Menstrual pain (premature tension/ presence/absence of pain at periods)
• Use of oral contraception
• Total number of pregnancies (Gravidity/G)
• Full term (Parity/P)
• Preterm
• Miscarriages
• Abortions (A)
• Living (L)
• Details of each pregnancy including mode
of delivery and complications
Gynecological History
• Age at menopause (if appropriate)
• Abdominal / pelvic pain
• Post-coital vaginal bleeding
• Intermenstrual bleeding
• Post-menopausal bleeding
• Abnormal vaginal discharge
• Dyspareunia
• Vulval skin changes and itching
• Sexual history if relevant to presenting complaint
• Any history of sexually transmitted diseases

PSYCHIATRIC HISTORY
• There is no fundamental difference between a psychiatric history and any other medical history.
• However psychiatric histories generally need to be more detailed and therefore take longer
because more information is needed about the patient’s personal life, developmental history,
family and social background.
• This is then combined with the mental status examination to produce a "psychiatric
formulation" of the person being examined.
• This is partly because laboratory tests and investigations also contribute so little to diagnosis.
• COASTMAP is a mnemonic acronym to remember key questions for a person's psychiatric
history.
C—Consciousness O—Orientation A—Activity S—Speech
T—Thought M—Memory A—Affect and mood P—Perception

72 11/28/2021
Mood Disorders
• Depression - "SIGECAPS“
(Low mood > 2 weeks)
 Sleep
 Interest (anhedonia)
 Guilt/worthlessness
 Energy ↓
 Concentration ↓
 Appetite/weight change
 Psychomotor slowing/agitation
 Suicide: thought/plan/access
• Mania - "GIDDINESS“ Grandiose
 Increased activity (goal directed/high risk)
 Decreased judgment
 Distractible
 Irritability
 Need less sleep
 Elevated mood
 Speedy talking
 Speedy thoughts
Grandiose – conceived on a very grand or ambitious scale

73 11/28/2021
Anxiety Disorders
• Generalized Anxiety Disorder (Excessive anxiety and worry that is difficult to control
 Restlessness (feeling “on edge” or “wound up”)
 Fatigue
 Concentration ↓
 Irritability
 Muscle tension
 Sleep problems
• Social Phobia (Social Anxiety Disorder - Fear/avoidance of social performance situations)
 Anticipates embarrassing oneself in social situations
 Hypersensitive to criticism
 May precipitate panic attacks
• Specific Phobia (May include animals, heights, blood/infection, flying, etc.)

74 11/28/2021
Panic disorder with/without agoraphobia
• Panic attacks may include:
 Shortness of breath
 Palpitations, pounding heart, or accelerated heart rate
 Sweating, trembling, shaking
 Feeling of choking
 Chest pain/discomfort
 Feeling nauseated, dizzy, faint, lightheaded
 Abdominal discomfort
 Derealization/depersonalization
 Fear of dying, losing control, going crazy
 Chills or hot flashes
 Paresthesias

75 11/28/2021
Obsessive-compulsive disorder (OCD)
• Obsession: a recurrent and persistent idea, thought, impulse, or image that is experienced as intrusive
and inappropriate that causes marked anxiety/distress . Themes include aggression, contamination,
symmetry, sexuality, hoarding, religion, somatic/appearance/body
• Compulsion: a repetitive, intentional behaviour performed in response to the obsession. Repetitive hand
washing, checking, counting, praying
Post-traumatic stress disorder (PTSD)
• Recurrent, intrusive recollections of the trauma
• Nightmares of the event
• Avoidance of stimuli associated with the trauma
• Illusions, hallucinations, dissociative “flash-backs”
• Sleep difficulties
• Irritability
• Decreased concentration
• Hypervigilance
• Startles easily
• Anhedonia, detachment from others, restricted range of affect

Psychosis
Positive symptoms
Hallucinations
Delusions
Negative symptoms
Flattened affect
Anhedonia
Avolition
Alogia
"Thought blocking"
Disorganization
Thinking
Speech
Behaviour
Cognitive symptoms
Memory impairment
Attention difficulties
Deficits in processing information
Catatonic symptoms
Posturing
Excess motor activity
Rigidity
Stupor
Eating Disorders
• Binging / purging /
restrictions / amenorrhea
• Perception of body image or
weight

77 11/28/2021
Attention-Deficit/Hyperactivity Disorder
• Inattention
 Often makes careless mistakes
 Difficulty sustaining attention
 Listening difficulties
 Difficulty organizing tasks and activities
 Avoids attention-heavy tasks
 Looses important items (e.g., keys, wallet, mobile phone)
• Hyperactivity and Impulsivity
 Fidgets with hands and feet
 Trouble remaining seated when expected
 Runs and climbs in inappropriate situations
 Unable to participate in leisurely activities
 Unable to be still for extended periods of time
 Talks excessively
 Trouble waiting for talk in conversation
 Trouble waiting for turn
 Interrupts or intrudes on others

79 11/28/2021
SEXUAL HISTORY
All the usual things: CC, history of PC, medical/surgical history, medications/allergies,
gynae history for women, social history PLUS the sexual history.
Principles
• Practice poker face (blank expression)
• Explain the need to take a sexual history:
• Language – make sure you both understand
• Confidentiality – room/ward, relatives, interpreters

80 11/28/2021
Questions related to occupational history
 Sexual orientation (person's feelings and sense of identity)
 Sexual coercion and abuse (tricked and forced)
 Sexual activity
 Number of partners
 Frequency of intercourse
 Type of sex practices
 STI history and risk assessment – (affect the Genital area - Sexually transmitted infections e.g. syphilis,
scabies., Medical conditions psoriasis, lichen planus, diabetes,, Side effects from medicines rash or dryness
etc)
 Pregnancy history and risk assessment
 Contraceptive behaviors (condom used / did it break etc)
 Medical procedures/blood transfusions
 Tattoos/piercings in non-professional place
 Substance use ( alcohol or drugs)
 Social history of partners (General health / known infection - Bacterial vaginosis, warts / use of Drugs
/alcohol / Smoking)

CONCLUSION ON HISTORY TAKING
• The history is the first step towards making a diagnosis.
• At this stage by analyzing the available information, it should be possible to reach a provisional
diagnosis. This will influence the emphasis placed on different components of the physical
examination.
• The flexible method of history taking is important for two reason.
1. In most instances it provides a clear indication of the nature of the problem.
2. It also forms the foundation of a satisfactory “PATIENT-DOCTOR RELATIONSHIP”
• The skill of history taking is not acquired overnight and it is not appropriate for a student to
ask highly personal or potential sensitive questions. However it should be undertaken by a
doctor who has clinical responsibility for the patient.
• Students & Recent graduates should therefore try to avail themselves of any opportunity to
“sit-in” during such a consultation.
History
(SAMPLE)
CC · HPI (OPQRST & ROS) · PMH · FH · SocHx · Allergies / Medications ·
Obs & Gynae history, Sexual history, Psychiatric history,

11/28/2021
83
Medical profession is now a days Medico-legal profession, so SAVE YOURSELF
Respect all……………………..Suspect all

Clinical Method - Patient history taking procedures

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