Here are the key points to cover in a systems review: - Briefly ask about symptoms related to major organ systems: cardiovascular, respiratory, gastrointestinal, genitourinary, neurological, musculoskeletal, skin, ears/nose/throat, eyes. - Ask focused questions about symptoms related to the presenting complaint and related systems. - Note any pertinent positives or negatives. No need to record if all negatives unless related to presenting complaint. - Aim to be thorough but brief. Focus on symptoms not covered elsewhere in history. - Document any significant findings to follow up in detail in HPI or PMH as needed.

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2. 2

3. What is History Taking?
• Listening to the patient
• Asking questions -- obtain information which
aid diagnosis
• Gathering information for the purpose of
generating differential diagnoses
3

4. Key Principles of Patient Assessment
• It is estimated that 80% of diagnoses are based
on history taking alone.
• Use a systematic approach.
• Practice infection control techniques.
• Establish a rapport with the patient.
• Ensure the patient is as comfortable as possible.
• Listen to what the patient says.

5. Key Principles of Patient Assessment
• Ensure consent has been gained.
• Maintain privacy and dignity.
• Summarise each stage of the history taking
process.
• Involve the patient in the history taking process.
• Maintain an objective approach.
• Ensure that your documentation (of the
assessment) is clear, accurate and legible.
5(Scott 2013, Talley and O’Connor 2010, Jevon 2009)

6. Assessment (Consultation) Model
BASICS
• Begining
1-Setting up :
Quiet , private space (curtains) in medical ward .
2-Starting assessment : (make sure you are talking to the
correct patient)
Stand on the right side
Greeting – shake hands with smile
Introduce yourself.
Take Permission
Proper Position
6

7. • Active Listening
• Be sensitive to your patients privacy and dignity .
• Respect for patient
• Good Rapport(communications)
• Systemic enquiry
Disease-oriented systematic enquiry
Dealing with patients feelings
Empathy : helping your patients feel that you
understand what they are going through
7

8. • Information Gathering
the exploration of the patient’s problem(s), in order to
discover:
 Biomedical perspective
 Patient’s perspective
 Background information
8

9. • Context
Understand your patients personal constraints and
supports , including where they live ,who they live
with , where they work ,who they work with , what
they actually do ,their cultural and religious beliefs ,
and their relationships and past experience .
It is about them as a person , it may not be
appropriate to explore these sensitive areas with
everyone .
Establish patients job and explore in some depth what
his job entails
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10. • Sharing information
• Achieving a shared understanding:
– Relates explanations to the patient.
– Encourages the patient to contribute.
• Planning, shared decision making:
– Shares own thinking as appropriate.
– Negotiates a plan.
– Checks with the patient about the plan of action.
Clarify and summarize
Use words that your patients understands and tailor your
explanation to your patient , you would use very different
terms when dealing with a lawyer as opposed to a farmer .
Speak clearly and audibly
Do not use jargon
Do not use unnecessarily emotive words 10

11. Summary
• Be systematic in your approach.
• Establish a rapport with the patient.
• Listen to what the patient is saying.
• Clarify and summarise information.
• Provide a ‘safety net’.
• Recognise own boundaries and seek senior
support.
• Escalate and/or refer to the appropriate person.
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12. Initiating the Session
12
•Preparation
•Establish rapport
•Identify the reason for
the consultation

13. Initiating the Session
Identifying the reason for the consultation
• Open questions:
– Always start with an open ended question and take
the time to listen to the patient’s ‘story’.
• Closed questions:
– Once the patient has completed their narrative to
closed questions which clarify and focus on aspects
can be used.
• Leading questions:
– Questions based on your own assumptions that lead
the patient to the answer you want to hear. These
should not be used at all.
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14. Initiating the Session
Identifying the reason for the consultation
Open questions:
- “How can I help you?”
- “You said you have pain on movement, can you tell me which
movements makes your pain worse?”
Closed questions:
- “Are you still taking the aspirin your GP prescribed?”
- “Is that an accurate summary of your symptoms?”
Leading questions:
- “You are not allergic to anything are you?”
- “Are your joints painful in cold weather?”
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15. Start with opening questions and actively listen to
patient (few minutes without interruption)
Useful opening questions might be :
D: What seems to be the problem?
D: Could you tell me why you have to come into
hospital?
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16. Establishing rapport
Non verbal communications
• S
• O
• L
• E
• R
16
Sits square on facing the patient
Maintains open body position
Leans slightly forward
Eye contact is maintained
Relaxed (in an appropriate posture)
(Kaufman 2008)

17. Responding to cues
• A Cue could be defined as a signpost to an area
in the history that you might otherwise ignore
but which may be very important to the patient .
• Cues are very common . They are often not
consciously presented by patients but offer an
insight into undeclared concerns .
• Does the patient catch his breath , change
breathing pattern ,become pale , or flushed , look
agitated , shows restless limb or body
movements ,become upset , or change eye
contact ? All these are recognized signs of stress
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18. • Examples of Verbal Cues include :
P: I hoped it wasn’t anything serious.
P: Its my chest again.
P: Of course it could just be stress .
There are also cues in the pitch , volume , rhythm of
speech and there may be cues in censored speech-
in what is not said .
P: Its no better (what's no better)
P:Im worried (about what)
P:I feel worse (worse than what or when )
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19. • Some times , patients use generalizations to express
their concerns :
P : I don’t like hospitals.
P : It never seems to get any better .
Cues may be non-verbal .
A patient may look sad or anxious and it might be
appropriate to respond :
D : You look worried about that .
Not all cues need an immediate response . Sometimes
retuning to it later is effective :
D : You mentioned earlier that you hadn't wanted to
come into hospital . was there anything worrying you
in particular about hospital?
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20. Initiating the Session
Establishing rapport
1. Providing false reassurance
2. Giving unwanted advice
3. Using authority
4. Using “why” questions
5. Using professional jargon
6. Using leading or biased questions
7. Talking too much
8. Interrupting or changing the subject
9.Writing answers of every questions in a paper
front of patient like police investigation
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Common Pitfalls of History Taking

21. Initiating the Session
• The practitioner’s role combines:
– Establishing rapport
– Listening
– Demonstrating empathy
– Facilitating
– Clarifying
NB: this role is performed throughout the whole history taking
and clinical examination process
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22. Gathering Information
• The practitioner’s role combines:
– Maintaining rapport
– Listening
– Demonstrating empathy
– Facilitating
– Clarifying
– Summarising
22

23. The stages for the interview
1. Establishing rapport
2. Invites the patient’s story
3. Establishing the agenda
4. Generating and testing diagnostic
hypotheses
5. Creating a share understanding of the
problem
6. Planning and close interview
23

24. Factors in establishing rapport
• Introduce yourself in a warm, friendly
manner.
• Maintain good eye contact.
• Listen attentively.
• Facilitate verbally and non-verbally.
• Touch patients appropriately.
• Discuss patients’ personal concerns.
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25. 2. Invites the patient’s story
• Use open-ended questions directed at the
major problem(s)
• Encourage with silence, nonverbal cues, and
verbal cues
• Focus by paraphrasing and summarizing
25

26. 3.Establishing the agenda
• Use open-ended questions initially
• Negotiate a list of all issues - avoid detail!
• Chief complaint(s) and other concerns
• Specific requests (i.e. medication refills)
26

27. 4.Generating and testing diagnostic
hypotheses
27

28. • 5.Creating a share understanding of the
problem
• Eliciting the patient’s perspective
• 6.Planning and close interview
28

29. Skills of interview
• Nonverbal
• Facilitation
• Reflection
• Clarification
• Summarization
• Validation
• Empathic responds
29

30. Types of Nonverbal
Communication
• Kinesics
• Paralanguage
• Vocal interferences
• Spatial Usage
• Self-presentation cues
30

31. Kinesics
• Eye Contact
• Facial expressions
• Emoticons
• Gesture
• Posture
• Touch
31

32. Touch
• Touching and being touched are essential to
a healthy life
• Touch can communicate power, empathy,
understanding
Paralanguage
• Pitch
• Volume
• Rate
• Quality
• Intonation 32

33. Vocal Interferences
• Extraneous sounds or words that interrupt
fluent speech
– “uh,” “um”
– “you know,” “like”
• Place markers
• Filler
33

34. Self-Presentation Cues
Physical Appearance
What message do you wish to send with your
choice of clothing and personal grooming?
34

35. 35
1. Introduction and identifying data
2.Presenting complaint(s) (PC)
3. History of presenting complaint(s) (HPC):
4.Systems review
5. Past/Previous medical history (PMH)
6. Drug history and Allergies
7. Social history (SH)
8. Family history (FH)
9. Patient’s ideas, concerns and expectations
• Principle complaint
• Details of current complaint
• Effects of complaint on activities of living
• SOCRATES or PQRSTA
• Past illnesses, hospitalisations, operations • Past treatments
• Occupation, Marital status, Accommodation,
Hobbies, Social life
• Smoking and alcohol consumption
• Diet, Sleeping, General wellbeing,
• Prescribed medication
• Over the counter medication / herbal remedies
• Any side-effects or problems with medication
• Any allergies

36. Taking history
• Identification:
Name,
age,
sex,
Date of admission (DOA) ,
Residence
Religion
Occupation
Marital status
36

37. Chief Complaint & Duration
• The main reason push the pt. to seek for
visiting a physician or for help
• Usually a single symptoms, occasionally more
than one complaints eg: chest pain,
palpitation, shortness of breath, ankle
swelling etc
• The patient describe the problem in their own
words.
• It should be recorded in pt’s own words.
• What brings your here? How can I help you?
What seems to be the problem?
37

38. Cheif Complaint (CC)
• Short/specific in one clear sentence
communicating present/major
problem/issue.
• Timing – fever for last two weeks or since
Monday
• Recurrent –recurring episode of abdominal
pain/cough
• Any major disease important with PC e.g.
DM, asthma, HT, pregnancy, IHD:
• Note: CC should be put in patient language.
38

39. History of Present Illness - Tips
• you should begin by inviting patients to provide an
account of recent events in their own words. Learn
to listen without interruption and encourage the
patient to continue the story right up to the time of
interview.
• When did you last feel fit and well?
• When did you first notice a change in your usual
state of health?
• What was the first symptom you noticed?
• When was that and what has happened since?
• What else have you noticed about your health?
• What has happened to you since you came
39

40. History of Present Illness - Tips
• Elaborate on the chief complaint in detail
• Ask relevant associated symptoms
• Have differential diagnosis in mind
• Lead the conversation and thoughts
• Decide and weight the importance of minor
complaints
• In details of present problem with- time of onset/
mode of evolution/ any investigation; treatment
&outcome/any associated +’ve or -’ve symptoms.40

41. Sequential presentation
• Always relay story in days before admission e.g. 1
week before the admission, the patient fell while
gardening and cut his foot with a stone
• Narrate in details – By that evening, the foot
became swollen and patient was unable to walk.
Next day patient attended Nuaman hospital and
they gave him some oral antibiotics. He doesn’t
know the name. There is no effect on his
condition and two days prior to admission, the
foot continued to swell and started to discharge
pus. There is high fever and rigors with nausea
and vomiting
41

42. • In details of symptomatic presentation
• If patient has more than one symptom, like chest
pain, swollen legs and vomiting, take each
symptom individually and follow it through fully
mentioning significant negatives as well. E.g the
pain was central crushing pain radiating to left
jaw while mowing the lawn. It lasted for less than
5 minutes and was relieved by taking rest. No
associated symptoms with pain/never had this
pain before/no relation with food/he is Known
smoker,diabetic & father died of heart attack at
age of 45
42

43. • Avoid medical terminology and make use of a
descriptive language that is familiar to them
• Describe each symptom in chronological order
• The symptoms of related system should be
described in history of present illness not on
ROS and mentioned even they are negative.
43

44. Pain
44
Site : somatic pain-well localized
Visceral pain – more diffuse (angina)
Onset : speed of onset and any
associations
Character : e.g. Sharp, dull, burning,
tingling, stabbing,crushing,
Radiation (of pain or discomfort) through
local extension or referred
Alleviating factors
Timing
Exacerbating factors
Severity
(Talley and O’Connor 2010)

45. Symptom analysis (OPQRSTAN)
• Onset of disease
• Position/site
• Quality, nature, character – burning sharp, stabbing,
crushing; also explain depth of pain – superficial or
deep.
• Relationship to anything or other bodily
function/position.
• Radiation: where moved to
• Relieving or aggravating factors – any activities or
position 45

46. • Severity – how it affects daily work/physical
activities. Wakes him up at night, cannot sleep/do
any work.
• Timing – mode of onset (abrupt or gradual),
progression (continuous or intermittent – if
intermittent ask frequency and nature.)
• Treatment received or/and outcome.
• Associated symptoms?.
• Negative : important
46

47. System Review (SR)
• This is a guide not to miss anything
• Any significant finding should be moved to HPI or
PMH depending upon where you think it belongs.
• Do not forget to ask associated symptoms of PC
with the System involved
• When giving verbal reports, say no significant
finding on systems review to show you did it.
However when writing up patient notes, you should
record the systems review so that the relieving
doctors know what system you covered
47

48. ROS
GENERAL
• Appetite
• Weight
• Sleep
• Fever
• Energy
48

49. Systems Review
Central Nervous System / Neurological: Eye:
Endocrine: Cardiovascular:
49
• Headaches
• Head injury
• Dizziness
• Vertigo
• Sensations
• Fits / faints
• Weakness
• Visual disturbances
• Memory and concentration changes
• Excessive thirst
• Tiredness
• Heat intolerance
• Hair distribution
• Change in appearance of eyes
• Chest pain
• Breathlessness
• Palpitations
• Ankle swelling
• Pain in lower legs when walking
• Visual changes
• Redness
• Weeping
• Itching / irritation
• Discharge

50. Systems Review
50
(Douglas et al. 2005)
Respiratory:
• Shortness of breath
• Cough
• Wheeze
• Sputum
• Colour of sputum
• Blood in sputum
• Pain when breathing
Gastrointestinal:
• Dental / gum problems
• Tongue problems
• Difficulty in swallowing
• Nausea
• Vomiting
• Heartburn
• Colic
• Abdominal pain
• Change of bowel habits
• Colour of stools
Ear, Nose and Throat: (often
incorporated into the Respiratory System
review)
• Earache
• Hearing deficit
• Sore throat

51. Systems Review
51
(Douglas et al. 2005)
Genitourinary system:
• Pain on urination
• Blood in urine
• Sexually transmitted infections
Women:
• Onset of menstruation
• Last menstrual period
• Timing and regularity of periods
• Length of periods
• Type of flow
• Vaginal discharge
• Incontinence
• Pain during sexual intercourse
Men:
• Hesitancy passing urine
• Frequency of micturition
• Incontinence
• Urethral discharge
• Erectile dysfunction
• Change in libido

52. Systems Review
52
(Douglas et al. 2005)
Head to ...
... toe
assessment
Musculoskeletal:
• Joint pain
• Joint stiffness
• Mobility
• Gait
• Falls
• Time of day of pain
Integumentary (Skin):
• General pallor of patient, e.g. pale,
flushed, cyanotic, jaundiced
• Rashes
• Lumps
• Itching
• Bruising

53. Past Medical History
• Start by asking the patient if they have
any medical problems
• IHD/DM/Asthma/HT/TB/Jaundice/Fits :E.g. if
diabetic- mention time of diagnosis/current
medication/clinic check up
• Past surgical/operation history
• E.g. time/place/ and what type of operation.
Note any blood transfusion and blood
grouping.
• History of trauma/accidents
• E.g. time/place/ and what type of accident
53

54. Drug History
• Drug History (DH)
• Any allergies to medications and what was the
reaction?(penicillin)
• Which medications are you currently taking:
– The name of the medication
– The dosage form
– How are they taking it (by which route)
– How many times a day
– For what reason (if not known or obvious)
54

55. ALLERGIES
• Do you have an allergy to or avoid any
medications due to side effects?
• What type of reaction do you have?
PRESCRIPTION MEDICATIONS
• What prescription medications do you take
on a regular basis?
• When do you take them?
NON-PRESCRIPTION MEDICATIONS
• What non-prescription over-the-counter
(OTC) medications do you take on a regular
basis?
• When do you take them?
HERBALS/SUPPLEMENTS/VITAMINS
• What herbal, natural or homeopathic
remedies do you take?
• What vitamins or minerals do you take?
• When do you take them?
• When do you take them?
55

56. Do you use any:
• eye drops
• nose sprays
• puffer (inhalers)
• medicated lotions or creams
• medicated patches
Do you receive any:
• needles (injections)
Do you take any medication
on a regular basis:
• for sleep
• for your stomach
• for your bowels
• for pain 56

57. Treatment abbreviations
• bd (Bis die) - Twice daily (usually morning and
night)
• tds (ter die sumendus)/tid (ter in die) = Three
times a day mainly 8 hourly
• qds (quarter die sumendus)/qid (quarter in die) =
four times daily mainly 6 hourly
• Mane/(om – omni mane) = morning
• Nocte/(on – omni nocte) = night
• ac (ante cibum) = before food
• pc (post cibum) = after food
• po (per orum/os) = by mouth
• stat – statim = immediately as initial dose
• Rx (recipe) = treat with
57

58. Family History
– Age, status (alive, dead) of relatives
– medical problems of relatives (ask about cancer,
especially breast, colon, and prostate; TB, asthma;
MI; HTN; thyroid disease; kidney disease; DM;
bleeding disorders)
– Write out or use a family tree.
58

59. 59

60. Social History
• patient profile (may include marital status and children,
financial support and insurance; education)
• Occupation :
Current and previous (clarify exactly what a job entails)
Exposure to hazards or irritants ,e.g.. chemicals, asbestos , flour
dust ..and use mask.
Effects of job on patient
Attidude of patient to job
Hobbies of keep birds --------- psittacosis pneumonia and extrinsic
allergic alveolitis .
Farmer--------- extrinsic allergic alveolitis .

61. Home circumstances
Type of home , owned or rented , rural or urban
Water supply , sewage system , animal breading
Travel history : (if suspect infectious disease )
Travel-induced : middle ear problems and deep vein
thrombosis .
Country-related: malaria , hepatitis A , HIV , Typhoid
fever , Hemorrhagic fever , Schistosomiasis
61

62. lifestyle risk factors
• Smoking history - amount, duration and type.
• Drinking history - amount, duration and type.
• Exercise history : do you take any regular exercise ,
how often? Do you use the stairs or lifts ?have you
had to reduce exercise because of illness?
• Diet history : do you have any dietary restrictions
and how have decide on these ? Frequency and
times of meals and variety and types of foods
eaten.
62

63. • Gyane/Obstetric history if female
• Immunization if small child
• Note: Look for the child health card.
• sexual history if suspected STD or infectious disease
Note:
• If small child, obtain the history from the care giver.
Make sure; talk to right care giver.
• If some one does not talk to your language, get an
interpreter(neutral not family friend or member also
familiar with both language). Ask simple & straight
question but do not go for yes or no answer.
63
Other Relevant History

64. Patient’s ideas, concerns and
expectations
• What have you thought might be causing your
symptoms?
• Is there anything in particular that concerns you?
• What have you been told about your illness?
• What do you expect to happen while you are in
hospital?
• Do you expect any difficulties in coping when you
go home?
• Do you have any questions you would like me to
pass on to the medical or nursing staff?
64

65. FIFE
Feelings related to illness (Concerns)
Ideas on what is happening to him (Beliefs)
Functioning in terms of the impact on daily life
Expectations of the illness
65

66. 66
“Medicine is learned at the
bedside and not in the
classroom”
(Sir William Osler 1849 – 1919)