This document provides guidance on taking a patient's medical history. It emphasizes the importance of history taking for diagnosis and outlines the key components to cover, including chief complaints, history of present illness, past medical history, family history, lifestyle factors, and a review of symptoms organized by body system. The document offers mnemonics like OPQRST, OLDCART and SOCRATES to structure the history of present illness. It also provides tips for asking open-ended questions, using patients' own words, and minimizing interruptions during the history. The overall aim of history taking is to understand a patient's health issues and problems in order to plan the next steps in evaluation and management.
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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)
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What is the purpose of the ‘interview?’
To identify ‘problems’.
To explore the health/illness of the patient
To plan for the next step...
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History Taking
History Taking - Assets
Being empathic
Being attentive
Being articulate (speak fluently and coherently)
Being friendly but business like
Being interested
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The Beginning!
Environment!
Introduce yourself
Ask permission to take the history
Have you got the correct person!!
Patients biographic data
Name
Address
Gender
Age
Marital status
Occupation
Religion
Family income/month/year
Educational qualification
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Structure
Biographic data
Chief Complaint
History of Present illness
Past medical history
Family history
Lifestyle/high risk
behaviour
Obstetrical history
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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 interruptions
Use reflection and summary when appropriate
Use the patient’s own words
Avoid technical terms
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CHIEF COMPLAINTS
Document in clients own words
e.g. pain
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HISTORY OF PRESENT ILLNESS:
Onset
Signs and symptoms
Duration
Treatment taken if any
Other complaints
loss of appetite
Insomnia
Disorders of stomach
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OPQRST
Onset
Pain, precipitating factors
Quality, quantity
Radiation, relieving factors
Severity/score, symptoms
Timing
• O
• P
• Q
• R
• S
• T
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OLDCART
Onset
Location (Site and radiation)
Duration (Fluctuating)
Character
Aggravating
Relieving features
Treatment
Associated symptoms
Previous episodes
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I.C.E.
Ideas – “Do you have any particular worries about this symptom?”
Concerns – “What is concerning you?”
Expectations – “What are you hoping for me to do for you today?”
(Moulton 2007)
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Past Medical History
Open questions
What illnesses have you had?
Childhood illness-mumps, measles etc
Any Medical disease (communicable and non-communicable)
Surgeries
Injuries
Blood transfusion
Medications
Use of over the counter products
Herbal or dietary supplements
Allergies
Psychiatric conditions if appropriate)
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Past Medical History
when?
any?
what?
previous
Vaccinations
Screening
Medicals
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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
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FAMILY HISTORY
Information about all family members
Father/ mother/grandparents/ brothers and sisters
Living or dead/ cause of death (if dead)
Condition of their health (if living)
Family history of any illness e.g. diabetes mellitus, cancer,
heart diseases etc
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Lifestyle history/risk behaviour
Occupation
Past and present
Exposure
Food habits/ food fads/likes/dislikes
Sleeping pattern
Exercise pattern
Alcoholism
Substance abuse
Tobacco
Duration
Type - pipe, cigarettes, cigars
Amount
If stopped when
Health care facility available
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Obstetrical History
Menstrual history
History of pregnancy
Labour
Puerperium
Complications, if any
History of children
Alive/dead
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Systematic Inquiry
General
Well being
Appetite
Sleep
Energy
Weight change
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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
