Basic History taken from patients in a clinical and Hospital Wards. Medical Colleges Students

1. Patientes HistoryTaking
Srabaz M. Abdalla
Lecturer
2nd year theoretical session of Taking Patients History.
College of Nursing
University of Sulaimani
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2. Structure of session
 Case report
 Intruduction and Describing Aim and Abjects
 Chief complaint
 History of present illness
 Past medical and surgical Histroy
 Drug History
 Family History
 Social History
 Systemic Review
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October 19,
2022
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Lecturer; Sarbaz M. Abdalla

3. A case Report
Importance of History Taking,
Explenation by a case Report
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October 19,
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Lecturer; Sarbaz M. Abdalla

4.  Part 1
 A 57 year-old male lorry driver, presented to his local emergency department (ER) with a 20-minute episode of
diaphoresis and chest pain. The chest pain was central, radiating to the left arm and crushing in nature.
The pain settled promptly following 300 mg aspirin orally and 800 mcg glyceryl trinitrate (GTN) (Angeside)
spray sublingually administered by paramedics in the community. He smoked 20 cigarettes daily (38 pack
years) but was not aware of any other cardiovascular risk factors. On examination he appeared comfortable and
was able to complete sentences fully. There were no heart murmurs present on cardiac auscultation. Blood
pressure was 180/105 mmHg, heart rate was 83 bpm and regular, oxygen saturation was 97%.
 What is the most likely diagnosis? ( Next Page)
A. Acute coronary syndrome B. Aortic dissection C. Oesophageal rupture D.Peptic ulceration E.Pneumothorax
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October 19,
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Lecturer; Sarbaz M. Abdalla
Importance of History Taking , Explenation by a case Report

5. Importance of History Taking , Explenation by a case
Report
A - Acute coronary syndrome Although the presentation could be attributable to any of the
above differential diagnoses, the most likely aetiology given the clinical picture and risk
factors is one of cardiac ischemia. Risk factors include gender, smoking status and age
making the diagnosis of acute coronary syndrome the most likely one. The broad
differential diagnosis in patients presenting with chest pain has been discussed extensively
in the medical literature.
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Lecturer; Sarbaz M. Abdalla

6. Importance of History Taking
Explenation by a case study
Depend on His History (part 1),
 which investigation must requested ?? (A)
 Which intervention requested . (B)
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October 19,
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Lecturer; Sarbaz M. Abdalla

7. Case Report : Part 2 (A)
An ECG was requested
and is shown in figure 1
ECG 30 minutes after admission
ECG on admission.
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October 19,
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Lecturer; Sarbaz M. Abdalla

8. Case Report : Part 2 (B)
A. Atenolol 25 mg, Atorvastatin 80 mg, Clopidogrel 75 mg, GTN 500 mcg
B .Atenolol 25 mg, Clopidogrel 75 mg, GTN 500 mcg, Simvastatin 20 mg
C .Atorvastatin 80 mg, Clopidogrel 300 mcg, GTN 500 mcg, Ramipril 2.5 mg
D .Atorvastatin 80 mg, Clopidogrel 75 mg, Diltiazem 60 mg, Oxygen
E .Clopidogrel 300 mg, Morphine 5 mg, Ramipril 2.5 mg,Simvastatin 20 mg
(C - Atorvastatin 80 mg, Clopidogrel 300 mcg, GTN 500 mcg, Ramipril 2.5
mg,) Wednesday,
October 19,
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Lecturer; Sarbaz M. Abdalla

9. Importance of History Taking Explenation by a
case Report.
30 minutes later the patient’s chest pain returned with greater
intensity whilst waiting in the emergency department. Now, he
described the pain as though “an elephant is sitting on his chest”.
The nurse has already done an ECG by the time you were called to
see him.
What would be the optimal management for this patient?
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October 19,
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Lecturer; Sarbaz M. Abdalla

10. Importance of History Taking
Explenation by a case Report
A. Administer intravenous morphine
B. Increase GTN dose
C. Observe as no new significant changes
D. Proceed to coronary angiography
E. Thrombolyse with alteplase
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Lecturer; Sarbaz M. Abdalla

11. - Proceed to coronary angiography The ECG shows ST
elevation in leads V2-V6 and confirms an anterolateral STEMI,
which suggests a completely occluded LAD.
- According to guidance, if the patient can undergo coronary
angiography within 120 minutes from the onset of chest pain,
then this represents the optimal management. If it is not
possible to undergo coronary angiography and potentially
percutaneous intervention within 2 hours, then thrombolysis
is considered an acceptable alternative.
- GTN and morphine administration can be considered in
parallel but they do not have a prognostic benefit.
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October 19,
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Lecturer; Sarbaz M. Abdalla
Importance of History Taking
Explenation by a case Report

12. Importance of History Taking
 Obtaining an accurate history is the critical first step in determining
the etiology of a patient's problem.
 A large percentage of the time (70%), you will actually be able make a
diagnosis based on the history alone.
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Lecturer; Sarbaz M. Abdalla

13. How to take a History ?
 The sense of what constitutes important data will grow exponentially in
future as you learn about the pathophysiology of disease.
 You are already in possession of the tools that will enable you to obtain a
good history.
 An ability to listen &ask common-sense questions that help define the nature
of a particular problem.
 A vast & sophisticated fund of knowledge not needed to successfully
interview a patient.
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Lecturer; Sarbaz M. Abdalla

14. General Approach
 Introduce yourself :
 Note – never forget patient THREE names
 Creat patient appropriately in a friendly relaxed way
 Confidentiality and respect patient’s privacy
 Try to see things from patient point of view. Understand patient underneath mental
status, anxiety, irritation or depression. Always exhibit neutral position.
 Listening
 Questioning: simple/clear/avoid medical terms/open, leading, interrupting, direct
questions and summarizing.
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Lecturer; Sarbaz M. Abdalla

15. Taking the History & Recording:
Always record personal details :
• Name
• Age
• Address
• Sex
• Ethnicity
• Occupation
• Marital status
• Religion
• Date of examination
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October 19,
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Lecturer; Sarbaz M. Abdalla

16. Complete History Taking:
 Chief complain
 History of present illness
 Past medical/Surgical Histroy
 Systemic review
 Family History
 Drug/blood transfusion history
 Social History
 Gyn/ob History
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October 19,
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Lecturer; Sarbaz M. Abdalla

17.  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?
Chief Complaint
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Lecturer; Sarbaz M. Abdalla

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

19. Duration: tips
 Exact duration.
 For how long you are ill.
 When you were completely normal.
 Is this complain for the first time or you have
other episodes.
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Lecturer; Sarbaz M. Abdalla

20. History of Present illness
 Details and Progression, regression off the
CC
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21. History of Present Illness-Tips
 Elaborate on the chief complaint in detail.
 Ask relevant associated symptoms.
 Have differntal diagnosis in mind.
 Lead the conversation and thoughts.
 Decide and weight the importance of minor
complaints.
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Lecturer; Sarbaz M. Abdalla

22. History of Presenting Complaint ( hpc)
 In details of present problem with time of onset/ mode of evolution/ any
investigation; treatment and outcome/any associated+’ve or –’ve symptoms.
 Sequental 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 the patient was
unable to walk . Next day patient attended 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 .
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October 19,
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Lecturer; Sarbaz M. Abdalla

23. History of Presenting Complaint ( hpc)
 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 and
father died of heart attack at age 45.
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October 19,
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Lecturer; Sarbaz M. Abdalla

24. History of Present illness
• Avoid medical terminology and make use of a
descriptive language that is familiar to them.
• Ask OPQRST for each symptom.
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October 19,
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Lecturer; Sarbaz M. Abdalla

25. Pain ( OPQRST )
 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
 Severity –how it affects daily work . Wakes him up at night, cannot sleep.
 Timing- mode of onset (abrupt or gradual), progression (continuous or intermttent- if intermittent
ask frequency/nature.)
 Treatment recieved or/and outcome. Wednesday,
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Lecturer; Sarbaz M. Abdalla

26. Past Medical Illness
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27. Past Medical/ Surgical History
PMH/PSH
• Start by asking the patient if they have any medical problems.
• IHD - Heart Attack- DM- Asthma- HT - RHD – TB – Jaundice - Fits: E.g. If
diabetic-mention time of diagnosis/current medication/clinic check up.
• Past surgical/operation history
• E.g time/place/what of operation
• Note any blood transfusion/blood grouping.
• H/O dental extraction/circumcision and any exessive bleeding during procedures.
• History of trauma/accidents
• E.g time/place what type of accident.
• Any minor operation or procedures including endoscopies, dental interventions, biopsies.
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Lecturer; Sarbaz M. Abdalla

28. Drug History
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29. Drug History
 Drug History (DH)
 Always use generic name or put trade name on bracelet with
dosage and timing
 Example: Ranitidine 150 mg BD PO
 Note: do not forget to mention: OTC/Vitamins/Traditional/Herbal
medicine and alternative medicine such as cupping or cuttery or
acupuncture.
 Blood transfusion
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Lecturer; Sarbaz M. Abdalla

30. Drug History
 Bd (bis die) – Twice daily (morning and night)
 Tds (ter dies sumendus)/TID(ter in die) = 3 times a day mainly 8 hourly
 Qds (quarter die sumendus)/QID(quarter in die) = 4 times daily 6 hourly
 Mane/(om-omni mane) = morning
 Nocte/(on-omni nocte) = night
 Ac (anti cibum) = before food
 Pc (post cibum) = after food
 Po (per orum/os) = by mouth
 Stat- statim = immedietly as initial dose
 Rx (recipe) = treat with
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Lecturer; Sarbaz M. Abdalla

31. Family History
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32. Family History
• Any familial disease/running in families E.g breast
cancer, IHD,DM, schizophrenia, development delay,
albinism.
• Infections running in families as TB, Leprosy
• Cholera, typhoid in case of epidemics.
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Lecturer; Sarbaz M. Abdalla

33. Social History
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Lecturer; Sarbaz M. Abdalla

34. Social History
• Smoking history- amount, duration and type.
• A strong risk factor for IHD.
• Alcohol history – amount, duration and type.
• Occupation, social and education background, ADI, family
social support and financial situation.
• Social class
• Home conditions such as:
• Water supply
• Sanitation status in his home and surrounding
• Animals/birds in there house Wednesday,
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Lecturer; Sarbaz M. Abdalla

35. Social History: smoking
 The most important cause of preventable disease.
 Smoking history – amount, duration and type.
 Amount : pack’’ year calculations.
 duration: continuous or interrupted.
 Any trials of quitting and how many
 Deep inhalation or superficial
 Active or passive smoker
 Type : self made, cigars, shesha, chewing etc
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Lecturer; Sarbaz M. Abdalla

36. Social History: smoking
 Ask the smoker whether he is willing to quit or not.
 Do not forget to encourage the smoker to quit whenever
contacting a smoker as it is proved to increase quitting rate.
 If he is with quit, but can not, help him by NRT, buperpion.
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October 19,
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Lecturer; Sarbaz M. Abdalla

37. Social History : Alcohol
 Whether drinking or not.
 If the person drinking is aware if it is healthy or not.
 Amount alcohol use (actually not healty at all):
• Men: 14 units/week, not 4 units/session
• Women: 7 units/week, not 2 units/session
• alcohol use is associated with cardiomyopathy, CVA , Myopathies, liver
cirrhosis and CNS dysfunction
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October 19,
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Lecturer; Sarbaz M. Abdalla

38. Social History : Alcohol
 Note: do not advise patients or individuals, to drink for Fun
because of:
• Religious and cultural reasons.
• Possibility of addiction with its known health problems.
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October 19,
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Lecturer; Sarbaz M. Abdalla

39. Other Relevant History
 Gyane/Obstertic history if female
 Gravida, para (G3P2), abortions, SZ sections, antenatal care and screens as
for Hep B and C.
 Immunization if small child
 Note: look for the child health card
 Travel / sexual history if suspected STDs or infectious disease
 Note: if small child obtains the history from the caregiver, make sure to talk to
right caregiver.
 If someone does not talk in your language, get an interpreter (neutral not
family friend or member also familiar with both languages) . Ask simple and
straight question but do not go for yes or no answer. Wednesday,
October 19,
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Lecturer; Sarbaz M. Abdalla

40. Social History
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Lecturer; Sarbaz M. Abdalla

41. Duration: tips
 Exact duration.
 For how long you are ill.
 When you were completely normal.
 Is this complain for the first time or you
have other episodes.
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October 19,
2022
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Lecturer; Sarbaz M. Abdalla

42. System Review (SR)
 This is a guide not to miss anything
 Any significant finding should be moved to HPC 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. Wednesday,
October 19,
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Lecturer; Sarbaz M. Abdalla

43. Wednesday,
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Lecturer; Sarbaz M. Abdalla
Hope slide