History taking in medicine is one of the challenge all medical students face. This brief guide was prepared based on the teachings of Prof.A.S.B.Wijekoon, Prof.I.Amarasinghe & many senior registrars/registrars met during my career. This explans the basics of what must be included in your history, how to plan your investigations/ treatment in a methodical way.

1. History taking in medicine
1.
P/C
Symptom X duration
e.g. Abdominal pain for 1 day
2.
There are ONLY 5 symptoms
1. Pain
2. ∆ Temperature
3. ∆ Shape: lump
4. Leakage of body fluids: h’rrhage
5. Loss of function
3.
4.
DD
Diseases could be either
Congenital
Acquired
1. Infective
2. Inflammatory
3. Neoplastic
4. Traumatic
5. Degenerative
6. Metabolic/ autoimmune
7. Vascular
5.
Symptom:
History of presenting complain must have following
1. Perspective
i.
Entirely new disease
ii.
New symptom of ongoing disease
iii.
Iatrogenic
2. Symptom analysis
3. Evolution, interventions
4. System review
5. Conclusion: current status, SOAP
i.
Subjective
ii.
Objective
iii.
Assessment-overall
iv.
Plan
5 components of diagnosis
1. Anatomy
2. Temporal nature (acute /chronic/ acute on
chronic)
3. Pathology
4. Etiology
5. complications/severity/extent
Problems
Medical: acute/ chronic
1. Illness/∆
a. Complications
i. Organ
ii. Distal organ
iii. General
2. Risk of illness
3. Socio-economic
Non-medical
To the patient
To the family
Investigations
Plan your investigations to
Confirm diagnosis
a. Anatomy: CXR
b. Pathology: CRP
c. Etiology: culture
Risk factors
a. Modifiable
b. Non-modifiable
Complications
a. Immediate
b. Late
c. Iatrogenic
Assessment of progression
a. TPR/ symptom chart
Prognosis
Your investigations could be
Lab
a. Hematological
b. Urine
c. Stools
d. CSF
e. Other swabs
f. Biopsy: BM, skin
Imaging
a. USS
b. Xray
c. MRI/CT
Minimally invasive: Endoscopy
Mx
1.
2.
3.
4.
5.
Symptomatic
Supporting
a. Feeding/fluid
b. Micturition
c. Bowel
d. Sleep/rest/activity
Specific
a. Anatomy
b. Pathology
c. Etiology
Prevention
a. Iry, notification IIry, IIIry
Rehabilitation
Pharmacological
Non- pharmacological
Mx of malignancy
1. Diagnosis
a. Gross anatomical
b. Histological
2. Staging
a. Distal METS
3. Assess other systems
a. Lung, liver, kidney, brain,
4. Optimization
a. Nutrition
5. Treatment
a. Curative
i. Medical
ii. Minimally invasive
iii. Surgical
b. Palliative
Yapa Wijeratne M/07/189