History Taking Method

1. TIPS ON HISTORY
TAKING
Prof. Dr. Aswinikumar
Surendran. MD
Professor of Medicine,
MCH TrivandrumModule No: 2

2. HISTORY TAKING
Story of the illness as narrated by the patient
Student or doctor elicits all the details
Then writes down in a specific format
What is meant by history taking?

3. HISTORY
It gives you a diagnosis in >70% of cases
Then investigate to confirm and localise
Then treat for a cure/symptom relief
Why is history taking very important?

4. DIAGNOSIS FROM HISTORY
Migraine, an important cause of headache
Diagnosis arrived at from history alone
No investigations needed - simply treat
Give an example?

5. DIAGNOSIS
Dia= Disease
Gnosis = Knowledge
Diagnosis = Knowledge about the disease
What is meant by “diagnosis”?

6. HISTORY TAKING
10-15' in a long case in examination
5-10' in the outpatient department
<5' in an emergency department
How much time to allot for history taking?

7. GREET THE PATIENT
Say “Hello” or “ Good Morning”
Introduce yourself as a medical student
Get permission for interview/examination
First of all

8. BUILD UP A RAPPORT
Common place of residence
Common nature of job of relatives
Common area of interest like computers
Find some way

9. TALK TO THE PATIENT DIRECT
Patient - best person to describe his illness
Only he can, describe sequence of events
And tell the severity and important ones
Not to the relative or bystander

10. NEED NOT TALK TO BYSTANDERS
Project their own ideas about the case
Give importance to details of their choice
Even interfere in interview /examination
May be unrelated/uneducated/employed

11. POSITION PATIENT CORRECTLY
Patient lying comfortably
Yourself standing on right side
Throughout the period of interview
Make yourself comfortable

12. NO NOTE-TAKING DURING HISTORY
Gets disinterested; even walk away
Instead use only small spiral books
Just note down forgettable things
Not in large note books in any case

13. CASE SHEET
Sit at some other place
Write legibly and beautifully
To read, understand and refer later
Better written later

14. HOW TO TAKE HISTORY
Name, age, sex
Residence, occupation, nature of work
IP number, Date of admission
First collect the patient details

15. PRESENTING COMPLAINTS
Major complaints of the patient
For which he has approached doctor
Or admitted to the hospital this time
What is meant by presenting complaints?

16. PRESENTING COMPLAINTS
To note key problems of the patient
In one look at the case sheet
In chronological order
What is the purpose?

17. PRESENTING COMPLAINTS
Fever, cough, hemoptysis
Abd pain, vomiting, loose stools
Weakness of upper and lower limbs
Only words or phrases

18. PRESENTING COMPLAINTS
Fever – 4 days
Cough – 3 days
Hemoptysis – 1 day
Put in a chronological order

19. HISTORY OF PRESENT ILLNESS
Whole story as narrated by patient
So be a “good listener” to the story
Later become a good “story teller”
Not the “h/o presenting complaints”

20. TAKE HISTORY IN 3 PHASES
First phase: Only narration by patient
2nd phase: Prompt to detail & expand
3rd phase: Make a systematic enquiry
Listen, prompt, enquire

21. FIRST PHASE
When did the first symptom start
Ask to tell the whole story till to date
Do not interrupt, allow him to finish
Last time apparently normal

22. SECOND PHASE
Fever – ask for details of fever
Cough – ask to detail sputum
Hempoptysis – Assess the quantity
Find out details of each

23. THIRD PHASE
Ask for cardinal symptoms
Select a list from each system
Find out each system is affected/not
Systematic enquiry

24. SYSTEMATIC ENQUIRY
CVS: Chest pain, dyspnoea, palpitation,
syncope
RS: Chest pain, cough, dyspnoea,
hemoptysis
GIT: Vomiting, loose stools, abdominal
pain
System wise

25. SYSTEMATIC ENQUIRY
CNS: Headache, weakness, numbness,
ataxia
MSS:
Muscle pain, arthralgia, neuralgia
HES:
Pallor, fatigue, bleedingtendencies
System wise

26. INVESTIGATION DETAILS
Details of all investigations
Done elsewhere in other clinics
Done after admission to this hospital
Make a detailed enquiry

27. TREATMENT DETAILS
Ask for all treatment received
Both in outside hospitals and inside
Tolerance to drugs and side effects
Make a detailed enquiry

28. H/O PAST ILLNESSES
Any similar illnesses in the past
Illnesses requiring prolonged rest
List: DM2/HTN/CAD/PTB/IH
All illnesses in past

29. PERSONAL HISTORY
Appetite, loss or gain in weight
Veg/non-veg, food for the day
Bladder/bowel/sexual habits
Regarding habits/what change occurred?

30. FAMILY HISTORY
Father/mother/brothers/sisters
Wife and children
Similar 3 step approach
All illnesses in members of family

31. SUMMARY OF NATURAL HISTORY
How the illness started?
How it progressed then?
What is the state now?
Put it in a nutshell

32. DIAGNOSTIC POSSIBILITIES
Give 4-5 broad diagnosis?
Give points in favour of diagnosis?
Give points against diagnosis?
From history alone