History taking is a crucial aspect of clinical practice aimed at gathering detailed information to diagnose and treat patients effectively. It involves communicating with the patient to understand their current symptoms, medical history, and relevant social factors, emphasizing the importance of good communication and careful attention during the process. The components of history taking include the patient's profile, chief complaint, history of present illness, past and family medical history, socio-economic background, review of systems, and physical examination.

1. History taking
DR. GOVINDA ROKAYA

2. What is History taking?
 It is an essential part of clinical practice,
providing critical information to help
diagnose and treat a patient
effectively. It involves asking the patient
or their family detailed questions to
understand the nature of their current
symptoms , past medical history, lifestyle
and any relevent social factors.

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. 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.

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

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

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

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

9. 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. Review of systems
8. Physical examination

10. 1. Patients profile
(Demographic data )
 Date and Time
 Name
 Age
 Sex
 Religion
 Marital status
 Occupation
 Address
 Who gave the history?

11. 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

12.  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

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

14. 3. History of the present
illness
 Onset: When did the problem start? Was it sudden or gradual?
 Location: Where is the problem (e.g., pain location, swelling)?
 Duration: How long has the patient been experiencing this issue?
 Character: What is the nature of the complaint (e.g., sharp, dull,
throbbing pain)?
 Aggravating/Relieving factors: What makes it worse or better (e.g.,
position, medication)?
 Associated symptoms: Are there any other symptoms that occurred
with the complaint (e.g., fever, nausea, shortness of breath)?
 Severity: How bad is the condition? (e.g., on a scale from 1-10)
 Previous episodes: Has this happened before? If so, how was it
managed?

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

16.  S - Site
Where is the symptom/pain located?
 O - Onset
When did the symptom start?
 C - Character
What is the nature of the symptom?
 R - Radiation
Does the symptom spread to other areas?
 A - Associated Symptoms
Are there any other symptoms accompanying the main complaint?
 T - Time
When does the symptom occur?
 E - Exacerbating/Relieving Factors
What makes the symptom worse or better?
 S - Severity
How bad is the symptom?

17. Example in Practice:
Patient's Complaint: "I've been having chest pain."
History Taking Using SOCRATES:
Site: "It’s right here, in the middle of my chest."
Onset: "It started about 2 hours ago after I finished eating."
Character: "It feels like a pressure, not sharp or stabbing."
Radiation: "Yes, the pain sometimes radiates to my left arm."
Associated Symptoms: "I feel a little short of breath, and I’m sweating
more than usual."
Time: "It’s been constant since it started, but it gets a little worse when I
walk around."
Exacerbating/Relieving Factors: "The pain doesn’t seem to go away
when I rest. I tried taking some antacid, but it didn’t help."
Severity: "I’d rate the pain as 7 out of 10, it’s quite uncomfortable."

18. 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

19. 5. Family history
 Genetic conditions: Any history of hereditary
diseases (e.g., heart disease, cancer, diabetes).
 Significant illnesses: Important family health patterns
(e.g., stroke, mental illness).
 Age of onset: When did family members develop
these conditions, and at what age?

20. 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

21. 7.Review of Systems (ROS)
A systematic review of various organ systems to identify additional
symptoms that the patient may not have mentioned yet.
 General: Weight loss/gain, fever, fatigue.
 Skin: Rashes, itching, changes in moles.
 Eyes: Vision changes, pain, discharge.
 Cardiovascular: Chest pain, palpitations, edema.
 Respiratory: Cough, shortness of breath, wheezing.
 Gastrointestinal: Abdominal pain, nausea, vomiting, diarrhea.
 Genitourinary: Urinary frequency, dysuria, blood in urine.
 Musculoskeletal: Joint pain, swelling, stiffness.
 Neurological: Headaches, dizziness, weakness, numbness.
 Endocrine: Excessive thirst, heat/cold intolerance.
 Psychiatric: Depression, anxiety, mood changes.

22. 8. Physical Examination
Basic methods
A. Inspection
• Pigmentation, asymmetry, oedemas, scars
• Lesions, erythemas, hematomas etc
B. Palpation
• Skin, muscle tonus, temperature, moisture
• Superficial vs. deep
• Pain, masses

23. C. Percussion
• Indirect percussion – “ finger on finger”
• Superficial vs. deep
• Quality of sound: resonance, hyperresonance,
tympanity, flatness, dullness
• Borders
D. Auscultation
• Indirect – stethoscope with membrane and bell
• Heart, lungs, intestines, vessels
E. Smell
• Hygiene, ketoacidosis, alcohol, bad breath,
foetor hepaticus

24. Physical examination
• General examination (general impression)
– Mental state, voice, speech, nutrition, posture,
walk
• Skin
– Pigmentations, rashes, moisture, elasticity
– Scars, hematomas, hemorrhages, erythemas

25. • Neck
– Stiffness
– Venous congestion
– Carotid stenosis
– Lymph nodes
• Thorax
– Normal shape and movements, breathing
– Breasts
• description in women >40 years
• Tenderness, masses, skin changes
• symmetry of areolae, discharge

26. – Axilla
• Lymph nodes
– Heart
• Normal heart sounds, clean tones, no murmurs,
respiratory arrhythmia
– Lungs
• Breathing sounds (stridor?) and frequency, resonant
percussion, borders
• Auscultation sounds - alveolar vs. tubal breathing, wet or
dry sounds, friction
murmur
• Spine
– Pain, stiffness, asymmetry – lordoses/ kyphoses/ scolioses

28. • Abdomen
– Symmetry: any signs of enlargements or masses? Hernia?
– Dilated veins – caput medusae
– Palpation: texture, tenderness/pain?, palpable spleen or
liver? –
borders, palpable masses or possible tumors?
• Appendicitis: Rowsing’s sign – palpation of LEFT
hypogastrium
» Plenie’s symptom – percussion tenderness of right
hypogastrium
– Percussion: borders of liver/spleen, tympanites?, ascites?
– Direct percussion of flanks – kidney tenderness?
– Auscultation: intestinal sounds
– Urinary bladder

29. • Ext. genitalia
– tumors, rash, discharge, pain
– Testes
• Rectal exploration
– normal tonus of sphincter, tumors
– Prostate: size (walnut), shape, consistency
– Brown faeces on glove

30. • Upper extremities
– Radial pulse
– Raynaud’s phenomenon (SLE)
– Finger clubbing
• Lower extremities
– Pulse of a. dorsalis pedis and a. tibialis posterior
– Ischemia – diabetic microangiopathy
– Edema, varicose veins
– Lymphedema - elephantiasis

31. • BASIC NEUROLOGICAL EXAMINATION
A. Cranial nerves
• N. olfactorius: rarely examined, smell
• N. opticus: normal visual fields, read letters on table, ophtalmoscopy
• N. oculomotorius: round pupils, reaction to light and accommodation
• N. trochlearis: no ptosis, paresis, deviation, nystagmus
• N. abducens: no pareses, double vision, movements (follow the finger),
normal saccadic movements
• N. trigeminus: normal sensibility for pain and touch in all three branches
• N. facialis: Asymmetry of face, normal force of muscles of forehead, eyes,
nose, mouth. central vs. peripheral paresis
• N. vestibulocochlearis: Normal hearing, conduction through air better than
through bone
• N. glossopharyngeus & vagus: normal voice, swallowing, elevation of uvula
and soft palate
• N. accessorius: turn head and lift shoulders symmetrically against resistance
• N. hypoglossus: no deviations upon protrusion of tongue, normal speech

32. General physical examination
 P - PALLOR
 I - ICTERUS
 L - LYMPHADENOPATHY
 C - CYANOSIS
 C - CLUBBING
 O - OEDEMA
 D - DEHYDRATION

33. PALLOR

34. ICTERUS

35. LYMPHADENOPATHY

36. CYANOSIS

37. CLUBBING

38. OEDEMA

39. DEHYDRATION

40. VITAL SIGNS
 TEMPERATURE
 PULSE RATE
 RESPIRATION RATE
 BLOOD PRESSURE
 SPO2