How to take medical history

1. History taking

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. Importance of History Taking?
► Obtaining an accurate history is the critical first
step in determining the etiology of a patient's
illness.
Diagnosis in medicine is based on
• Clinical history
• Physical Examination
• Investigations

4. • A large percentage of the time (70%),
you will actually be able make a
diagnosis based on the history alone.

5. How to take a history ?
“Always listen to the patient
they might be telling you the
diagnosis”. (Sir William Osler 1849 - 1919)
The basis of a true history is good communication
between doctor and patient.
It takes practice, patience, understanding and
concentration.

6. Approach to history taking
 Your look is important
Your dressing

7.  Introduce your self and create a rapport
Approach to history taking

8.  Be alert and pay full attention
Approach to history taking

9. ► Ensure consent has been gained.
► Maintain privacy and dignity.
► Ensure the patient is as comfortable as
possible
Summarise each stage of the history taking
process.
Involve the patient in the history taking
process
Approach to history taking

10. “If in a bad mood or distracted
during the consultation, you can
end up making a history rather
than taking a history”.

11. Components of History taking
1. Patient’s profile
2. Chief complaint
3. History of the present illness
4. Past medical history
5. Family history
6. Socioeconomic history
7. System Review

12. 1. Patients profile
 Date and Time
 Name
 Age
 Sex
 Religion
 Marital status
 Occupation
 Address
 Who gave the history?

13. 2. Chief complaint
 The main reason for which the patient is trying to seek
medical help by visiting the physician.
 Usually a single symptoms, occasionally more than
one complaints eg: fever, headache, pain, etc
 The patient describe the problem in their own words.
 It should be recorded in patients own words.
 The complain should be recorded with their onset
duration

14.  How to ask for chief complaint?
• What brings your here?
• How can I help you?
• What seems to be the problem?
 If there is more than one complaint, it should be
written according to chronological order
2. Chief complaint

15. 2. Chief complaint
Example,
 Fever-2 weeks,
 Productive cough-1 week,
 Vomiting -2 days,
 Fatigue-1day,

16. 3. History of the present illness
 Elaborate on the chief complaint in detail
 Ask relevant associated symptoms
 Gain as much information you can about the specific
complaint.
 Lead the conversation by asking questions.
 Always start with an open ended question and take
the time to listen to the patient’s ‘story’.
 Once the patient has completed their narrative then
closed questions can be asked to clarify .
 Leading question are to be avoided.

17.  Open questions allow patients to express their
own thoughts and feelings, e.g. 'Is there anything
else that you want to mention?’
 Closed questions are requests for factual
information, e.g. 'When did this pain start?’
 Leading questions are based on your own
assumptions that lead the patient to the answer
you want to hear.
3. History of the present
illness

18.  In details of present problem with- time of onset/
mode of evolution/ any investigation;treatment
&outcome/any associated +’ve or -’ve symptoms.
 Avoid medical terminology and make use of a
descriptive language that is familiar to patients
 Sequential presentation
 Always relay story in days before admission
 Narrate in details
3. History of the present
illness

19. 3. History of the present
illness
 Tips to gather information:
• S
• O
• C
• R
• A
• T
• E
• S
Site
Onset
Character
Radiation (of pain or discomfort)
Alleviating factors
Timing
Exacerbating factors
Severity (

20. The patient was apparently well 1 week before the
admission when 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 a private clinic where they gave him some oral
medicines. The patient doesn’t know the name of the
medicines given but says that he was told the medicine
would suppress his leg pains .however There was no
improvement in his condition. Two days prior to
admission in JNMC, the swelling in the foot started to
discharge pus. There is high fever and rigors with nausea
and vomiting.
3. History of the present
illness

21. 4. Past medical history
 Any history of similar complaint in the past
 Other medical problems the patient has or had
 Any chronic disease present like hypertension,
diabetes etc
 Past hospitalizations and past surgeries
 Medications if any taken in the past (dosage and
duration)
 Allergies
 Pediatric: Birth history, Developmental
Milestones, Immunizations
 Gyane/Obstetric history if female

22. 5. Family history
 It is important to establish whether there are any
genetically transmitted diseases within families
 Any illness run in thefamily?
 Similar history in the family,
 Parents and siblings suffering with any chronic illness,
 Parents if died, how old and what they died of
 You should be able to collect relevant family history
depending upon the present illness.
 Example, Patient has come due anemia ,
Try to rule out sickle cell, thalasemia/ G6PD deficiency

23. 6. Socioeconomic history
 Smoking history - amount, duration and type.
 Drinking history - amount, duration and type
 Any drug addiction
 Sexual history if suspected STI
 Occupation, social and education background,
financial situation

24. 7. System Review
Cardiovascular
•Chest pain
•Paroxysmal Nocturnal Dyspnoea
•Orthopnoea
•Short Of Breath
•Cough/sputum (
•Palpitations
•Cyanosis
Respiratory System
•Cough(productive/dry)
•Sputum (colour, amount, smell)
•Haemoptysis
•Chest pain
•SOB/Dyspnoea
•Tachypnoea
•Hoarseness
•Wheezing
General
•Weakness
•Fatigue
•Anorexia
•Change of weight
•Fever
•Lumps
•Night sweats
Gastrointestinal/Alimentary
•Appetite (anorexia/weight change)
•Diet
•Nausea/vomiting
•Regurgitation/heart burn/flatulence
•Difficulty in swallowing
•Abdominal pain/distension
•Change of bowel habit
•Haematemesis, melaena
•Jaundice

25. Urinary System
•Frequency
•Dysuria
•Urgency
•Hesitancy
•Terminal dribbling
•Nocturia
•Back/loin pain
•Incontinence
•Character of urine:color/
amount (polyuria) & timing
•Fever
Genital system
•Pain/ discomfort/ itching
•Discharge
•Unusual bleeding
Nervous System
•Visual/Smell/Taste/Hearing/
Speech
•Head ache
•Fits/Faints/Black outs/loss
of consciousness(LOC)
•Muscle weakness/ numbness/
paralysis
•Abnormal sensation
•Change of behaviour or psyche
Musculoskeletal System
•Pain – muscle, bone, joint
•Swelling
•Weakness/movement
•Deformities
7. System review

26. Now you’ve got your
information
 Give a Summary
 Ask if you’ve understood the information
correctly
 Ask if there is any other information that the
patient wants you to know
 Advise what your plan would be
 Check with the patient that they are in
agreement with your plan