The document provides a detailed overview of the history taking process in medicine, emphasizing its importance for diagnosis and patient care. It outlines the approach, components, and techniques of effective history taking, including how to ask questions and gather relevant patient information. Key components include the patient's profile, chief complaint, history of present illness, past medical and family histories, and various physical examination methods.

1. History taking
DR. GOVINDA ROKAYA

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. 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. ► 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

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

10. 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

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

12. 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

13.  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

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

15. 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.

16.  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

17.  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

18.  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 (

19. 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 MANTRA ,
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

20. 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

21. 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

22. 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

23. 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

24. 7. 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

25. 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

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

27. • Head
– Direct percussion of skull
– CN V exit points – tenderness?
– CN VII – make grimaces
– CN XII – protrude tongue
– Eyes: conjunctiva, pupils round and equal (CN III)
– anisocoria?, symmetric accommodation reflex
and reaction to light, movements, eyelids
– Mouth: teeth (prostheses), moist and clean
mucosa and tongue, central cyanosis

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

29. – 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
– Ex. Schober’s distance test, Stibor’s distance test

30. • 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

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

32. • 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

33. • 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. Sentral 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

34. B. Mobility
• Bradykinesia, dyskinesia, akinesia, tremors
• Rigidity, spasticity, hypotonicity
C. Force
• Muscle force over joints: shoulders, elbows, fist, hip, knee, ankle
• Tempo and fine motor skills
D. Coordination
E. Reflexes
• Each side
• Biceps, triceps, radial
• Patellar, achilles, plantar
F. Sensibility
• Normal sensibility for pain, touch and temperature
G. Balance and walking
• Normal walk, stand on heels and toes, rise up from crouching position

35. 8. Systemic Examination
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
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

36. 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
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