History taking is an important aspect of medicine

1. WEEK
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Slide 1 of 49 MPHM14 OSPAP Clinical Skills
OSPAP Programme
Clinical History Taking
BY: DR. K.S.K JUSU
Department of internal medicine
MAKENI SCHOOL OF CLINICAL
SCIENCES

2. WEEK
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Slide 2 of 49 MPHM14 OSPAP Clinical Skills
Aims
Be able to:
• Understand the importance of the medical history
• Identify the relevant processes involved in taking a medical
history
• Recognise the importance of structure in a systematic
approach to history taking
• Understand the importance of ‘red flags’
• Be able to take a systematic, comprehensive history from a
patient

3. WEEK
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Slide 3 of 49 MPHM14 OSPAP Clinical Skills
Why?
“Without a good history it is an inevitable fact
that the patient’s problem will remain
undiagnosed, despite examination findings and
the results of investigations that follow”
(Fishman & Fishman 2005)

4. WEEK
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Slide 4 of 49 MPHM14 OSPAP Clinical Skills
History Taking
…is arguably the most important aspect of
patient assessment, and is increasingly being
undertaken by health professionals other than
doctors
(Crumbie 2006)

5. WEEK
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Slide 5 of 49 MPHM14 OSPAP Clinical Skills
The Importance of History Taking!
• 80% of diagnoses in general medical clinics are
based on the interview (Epstein et al 2003)
• 76% correct diagnosis after taking a clinical
history only (Peterson et al 1992)
• 83 % of doctors made correct diagnosis on the
basis of medical history only (Hampton et al
1975)

6. WEEK
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Slide 6 of 49 MPHM14 OSPAP Clinical Skills
What is the purpose of the ‘medical interview?’
• To identify ‘problems’.
• To explore the health/illness of the patient
• To plan for the next step...

7. WEEK
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Slide 7 of 49 MPHM14 OSPAP Clinical Skills
History Taking
History Taking - Assets
• Being empathic
• Being attentive
• Being articulate
• Being friendly but business like
• Being interested

8. WEEK
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Slide 8 of 49 MPHM14 OSPAP Clinical Skills
The Beginning!
• Environment!
• Introduce yourself
• Ask permission to take the history
• Have you got the correct person!!
• Patients Demographics
– Name
– Age
– Occupation
– Background

9. WEEK
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Slide 9 of 49 MPHM14 OSPAP Clinical Skills
Structure
There is no evidence to support any particular
structure in taking a history. However the
following can be utilised -

10. WEEK
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Slide 10 of 49 MPHM14 OSPAP Clinical Skills
General Principles
• Let the patient tell their story
• Listen
• Develop a rapport, be friendly
• Be interested
• Use eye contact
• Use appropriate language and terms

11. WEEK
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Slide 11 of 49 MPHM14 OSPAP Clinical Skills
History taking
THE PATIENT IS THE MOST IMPORTANT
PERSON IN THE ROOM!
‘Always listen to the patient, they might be
telling you the diagnosis’
Sir William Osler

12. WEEK
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Slide 12 of 49 MPHM14 OSPAP Clinical Skills
Set the Agenda
• Use open-ended questions initially
• Negotiate a list of all issues - avoid detail!
• Presenting complaint(s) and other concerns
• Specific requests (i.e. medication refills)
• Clarify the patient's ideas, concerns
expectations (ICE)
• "Why now?"

13. WEEK
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Slide 13 of 49 MPHM14 OSPAP Clinical Skills
History Taking
Allow the patient time to tell the story in their own words.
If you don’t understand something imply the problem is
yours!
If you are unsure about the main problem –
“If I could make just one thing better what would it be?”

14. WEEK
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Slide 14 of 49 MPHM14 OSPAP Clinical Skills
History Taking
Pitfalls
1.The patient does not always know what is and what is not
relevant
o Hence the importance of a systematic enquiry
2.The patient has an almost universal tendency to describe
his/her symptoms not directly but in terms of what he/she
thinks they are due to e.g. Neuritis, Rheumatism
o What do you mean by?

15. WEEK
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Slide 15 of 49 MPHM14 OSPAP Clinical Skills
History Taking
Examples of techniques
Open enquiries
e.g. Tell me about your pain?
How did you react to the tragedy?
Closed inquiries
When did your pain begin?

16. WEEK
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Slide 16 of 49 MPHM14 OSPAP Clinical Skills
Structure
• Presenting Complaint
• History of Presenting
Complaint
• Past medical history
• Drugs (medications/allergies)
• Family history
• System enquiry
• Social history
Polly (Peter)
Has
Pretty
Damn
Fine
Sexy (smelly)
Stockings (socks)

17. WEEK
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Slide 17 of 49 MPHM14 OSPAP Clinical Skills
History Taking
Open questions
Clarification
Reflection - involves putting back to the
patient a symptom or remark
Summary - an expansion on reflection

18. WEEK
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Slide 18 of 49 MPHM14 OSPAP Clinical Skills
History Taking
Key points
• What to ask and how to ask it
• Open ended questions are better than closed questions in
establishing framework of the history
• Closed questions provide detail and sharpen the account
• Keep the history flowing
• Minimum of interuptions
• Use reflection and summary when appropriate
• Use the patient’s own words
• Avoid technical terms

19. WEEK
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Slide 19 of 49 MPHM14 OSPAP Clinical Skills
Developing A Structure

20. WEEK
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Slide 20 of 49 MPHM14 OSPAP Clinical Skills
OLDCART
Onset
Location (Site and radiation)
Duration (Fluctuating)
Character
Aggravating
Relieving features
Treatment
Associated symptoms
Previous episodes

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Slide 21 of 49 MPHM14 OSPAP Clinical Skills
SOCRATES
Site
Onset (gradual/sudden)
Character
Radiation
Associations (other symptoms)
Timing/duration
Exacerbating/relieving factors
Severity (pain score)

22. WEEK
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Slide 22 of 49 MPHM14 OSPAP Clinical Skills
Past Medical History
Open questions
What illnesses have you had?
(include psychiatric conditions if appropriate)

23. WEEK
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Slide 23 of 49 MPHM14 OSPAP Clinical Skills
Past Medical History
when?
any?
what?
previous
Vaccinations
Screening
Medicals
alcohol
smoking

24. WEEK
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Slide 24 of 49 MPHM14 OSPAP Clinical Skills
History Taking
Drug History
• Not just prescribed drugs - include over the counter remedies
and alternative medicine
• Name each substance, dose and duration
• Compliance
• Drug allergies & sensitivities

25. WEEK
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Slide 25 of 49 MPHM14 OSPAP Clinical Skills
Medication and Allergies
• Medication
– name if possible
– Dose
– Route of administration
– Recent change
– Include OTC and homeopathic / herbal
– Recreational drugs
• Allergies & Sensitivities
– When? Diagnosed?
– How presented, symptoms

26. WEEK
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Slide 26 of 49 MPHM14 OSPAP Clinical Skills
History Taking
Family history
• Open question - ‘tell me about any illness(es) which run in the
family
• Ask specifically about immediate family including parents
• Diagnosis and age
• Cause of death

27. WEEK
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Slide 27 of 49 MPHM14 OSPAP Clinical Skills
Social History
• Family situation
• Relationships incl. Marital status
• Occupation
– Past and present
– Exposure
• Community Involvement & Network
• Hobbies

28. WEEK
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Slide 28 of 49 MPHM14 OSPAP Clinical Skills
Social History
Alcohol history
Quantity and type
Place of drinking
Alone or accompanied
Money spent
Purpose

29. WEEK
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Slide 29 of 49 MPHM14 OSPAP Clinical Skills
Social History
Tobacco
Duration
Type - pipe, cigarettes, cigars
Amount
If stopped when

30. WEEK
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Systematic Inquiry
General
Well being
Appetite
Sleep
Energy
Weight change

31. WEEK
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Slide 31 of 49 MPHM14 OSPAP Clinical Skills
Systemic Enquiry
• Direct questioning
• Organise symptoms by system
• Explore any positives with open ended
questions and then clarify as per presenting
complaint
• Use lay terms
• Summarise
• Anything else?

32. WEEK
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Slide 32 of 49 MPHM14 OSPAP Clinical Skills
Systemic Enquiry
C.V.S.
• Chest pain
• Breathlessness
– On exertion
– Lying flat
– Wake up at night
– Orthopnoea
• Palpitations
• Ankle swelling
• Exercise Tolerance
• Pain in legs when walking

33. WEEK
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Slide 33 of 49 MPHM14 OSPAP Clinical Skills
Systemic Enquiry
R.S.
• Shortness of breath
• Chest pain
– On inspiration
• Cough
• Sputum
– Blood
• Wheeze

34. WEEK
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Slide 34 of 49 MPHM14 OSPAP Clinical Skills
Systemic Enquiry
GI System
• Dental / Gum Problems
• Reduced appetite/weight loss
• Swallowing
– painful
– difficult
• Indigestion, heartburn
• Abdominal pain
• Vomiting
• Altered bowel habit
• Blood loss

35. WEEK
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Slide 35 of 49 MPHM14 OSPAP Clinical Skills
Systemic Enquiry
Urogenital
Pain on passing urine
Frequency - day, night
Colour of urine
Males: (age), difficulty starting, poor stream,
dribbling, discharge, libido
Females: menarche, menopause, frequency,
regularity, urge or stress, incontinence,
discharge, abnormal bleeding, libido

36. WEEK
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Slide 36 of 49 MPHM14 OSPAP Clinical Skills
Systemic Enquiry
CNS
• Weakness
• Disturbance of sensation
• Headaches
• Visual disturbance
• Dizziness, blackouts (clarify these)
• Fits
• Confusion
• Disturbance of speech
• Hearing

37. WEEK
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Slide 37 of 49 MPHM14 OSPAP Clinical Skills
Systemic Enquiry
Locomotor
• Joint Pain
• Joint Stiffness
• Swelling
• Mobility
• Gait
• Falls
• Redness and warmth

38. WEEK
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Slide 38 of 49 MPHM14 OSPAP Clinical Skills
Systemic Enquiry
The Skin
• Rash
• Spots
• Itching
• Ulcers
• Lumps/growths

39. WEEK
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Slide 39 of 49 MPHM14 OSPAP Clinical Skills
Summary
• Salient features of
– Presenting history
– Relevant past history
– Background
• Differential diagnosis

40. WEEK
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Slide 40 of 49 MPHM14 OSPAP Clinical Skills
History Taking
Explanation
• Most important from the patients point of view
• Communication skills are vital
• Speak clearly and audibly
• Avoid jargon
• Avoid emotive words
• Most important information first

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Slide 41 of 49 MPHM14 OSPAP Clinical Skills
Questions /
thoughts?