Patient Examination: History

By
Dr Monkez M Yousif
Professor of Internal Medicine
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.
There is no single, correct way to take a history; with time you
will develop your own style; however, one effective and
commonly used sequence comprises:

Introduction and identifying data
Presenting complaint (CC)
History of present illness (HPI)
Past medical history (PMH)
Family history
Social and personal history
Review of system (ROS)
Patients ideas, concerns and expectations
How to take a history?
Introduce yourself.
Note never forget patient names
Prepare the patient appropriately in a friendly relaxed way.
Confidentiality and respect patient privacy.
General Approach
Try to see things from patient point of view. Understand
patient underneath mental status, anxiety, irritation or
depression.
Listening
Questioning: simple/clear/avoid medical terms/open,
leading, interrupting, direct questions and summarizing.
Always record personal details:
name,
age,
address,
sex,
ethnicity,
occupation,
marital status.
Record date of examination
Taking the history & Recording
Complete History Taking
Chief complaint
History of present illness
Past medical history
Systemic enquiry
Family history
Drug history
Social history
CHIEF COMPLAINT
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.

What brings your here? How can I help you?
What seems to be the problem?
Chief Complaint
Chief Complaint
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

Complete History Taking
Chief complaint
History of present illness
Past medical history
Systemic enquiry
Family history
Drug history
Social history
History of Present Illness
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
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 hospital and they gave him some oral
antibiotics. He doesnt 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.
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 & father died of heart attack at
age of 45.
In details of present problem with- time of onset/ mode of evolution/ any
investigation; treatment &outcome/any associated +ve or -ve symptoms.
History of Present Illness - Tips
Avoid medical terminology and make use
of a descriptive language that is familiar to
them

Ask OPQRST for each symptom
Pain (OPQRST)
Position/site
Severity how it affects daily work/physical activities. Wakes
him up at night, cannot sleep/do any work.
Relationship to anything or other bodily function/position.
Radiation: where moved to
Relieving or aggravating factors any activities or position
Quality, nature, character burning sharp, stabbing, crushing;
also explain depth of pain superficial or deep.
Timing mode of onset (abrupt or gradual), progression
(continuous or intermittent if intermittent ask frequency and
nature.)
Treatment received or/and outcome.
Onset of disease
Are there any associated symptoms?
Past Medical Illness
Past Medical History
Start by asking the patient if they have any
medical problems

IHD/Heart Attack/DM/Asthma/HTN/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/ 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


Drug History
Drug History
Always use generic name or put trade name
in brackets with dosage, timing and how
long. Example: Ranitidine 150 mg BD PO
Note: do not forget to mention
OCP/Vitamins/Traditional medicine
Drug History
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
AM/(om omni mane) = morning
PM/(on omni nocte) = night
po (per orum/os) = by mouth
stat statim = immediately as initial dose
Rx (recipe) = treat with

Family History
Family History
Any familial disease/running in families e.g.
breast cancer, IHD, DM, schizophrenia,
Developmental delay, asthma, albinism
Social History
Social History
Smoking history - amount, duration and
type. A strong risk factor for IHD
Drinking history - amount, duration and
type. Cause cardiomyopathy, vasodilatation
Occupation, social and education
background, family social support and
financial situation

Other Relevant History

Gyane/Obstetric history if female

Immunization if small child

Travel and sexual history if suspected STI or infectious
disease

Language Barrier: 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.

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.
System Review
Respiratory System
Cough(productive/dry)
Sputum (colour, amount, smell)
Haemoptysis
Chest pain
SOB/Dyspnoea
Tachypnoea
Hoarseness
Wheezing
Cardiovascular
Chest pain
Paroxysmal Nocturnal Dyspnoea
Orthopnoea
Short Of Breath(SOB)
Cough/sputum (pinkish/frank blood)
Swelling of ankle(SOA)
Palpitations
Cyanosis
Gastrointestinal/Alimentary
Appetite (anorexia/weight change)
Diet
Nausea/vomiting
Regurgitation/heart burn/flatulence
Difficulty in swallowing
Abdominal pain/distension
Change of bowel habit
Haematemesis, melaena, haematochagia
Jaundice
General
Weakness
Fatigue
Anorexia
Change of weight
Fever
Lumps
Night sweats
System Review
Urinary System
Frequency
Dysuria
Urgency
Hesitancy
Terminal dribbling
Nocturia
Back/loin pain
Incontinence
Character of urine: color/
amount (polyuria) & timing
Fever
Nervous System
Visual/Smell/Taste/Hearing/Speech
problem
Head ache
Fits/Faints/Black outs/loss of
consciousness(LOC)
Muscle weakness/numbness/paralysis
Abnormal sensation
Tremor
Change of behaviour or psyche
Genital system
Pain/ discomfort/ itching
Discharge
Unusual bleeding
Sexual history
Menstrual history menarche/ LMP/ duration
& amount of cycle/ Contraception
Obstetric history Para/ gravida/abortion
Musculoskeletal System
Pain muscle, bone, joint
Swelling
Weakness/movement
Deformities
Gait
SOAP
Subjective: how patient feels/thinks about him. How does he look.
Includes PC and general appearance/condition of patient
Objective relevant points of patient complaints/vital sings, physical
examination/daily weight,fluid balance,diet/laboratory investigation
and interpretation
Plan about management, treatment, further investigation, follow up
and rehabilitation
Assessment address each active problem after making a problem
list. Make differential diagnosis.
Patients 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?
Special Challenges
Sensitive Topics
The Right Location
Does anyone present make the patient feel
uncomfortable?
Gaining Trust
Choosing Appropriate Words
Understand the patients feelings related to the
sensitive nature
Be Professional
Special Challenges
The Silent Patient
Short periods of silence may be normal
Allow time to collect thoughts
Provide reassurance & encouragement
Consider:
You have frightened the patient
You are dominating the discussion
You have offended the patient
There is a physical or mental disorder
Special Challenges
The Overly-Talkative Patient
Allow patient to speak
If necessary, politely interrupt and focus the
discussion
Focus on most critical issue
Ask specific, closed-ended questions
Summarize the patients story and move on
Dont display your impatience
Special Challenges
The Anxious or Frightened Patient
Look for signs of anxiety or fear
Try to alleviate concerns & develop trust
No false reassurance
Everything is going to be fine
Identify the source of anxiety/fear
Understand the patients feelings
I dont know why you are so anxious
Special Challenges
The Angry or Hostile Patient
Common feelings with stress or fear
Understand the source of these feelings
Respond in a professional & caring manner
Personal Safety is a primary concern!!!
Distance
Assistance
Firm but caring verbal & body language
Special Challenges
The Intoxicated Patient
Irrational
Altered sense of right & wrong
May become violent
If patient is shouting,
increased potential for violent behavior
listen
dont respond back with shouting
have assistance for safety
Special Challenges
The Depressed or Suicidal Patient
Know the warning signs
Explore the specific feelings of the patient
Be direct and specific
Question regarding thoughts of suicide or personal harm
Talk openly and specifically about suicide plans
Special Challenges
The Patient with Confusing Behavior or
History
The entire history does not add up
Assess mental status
Consider possible dementia or delirium
Identify cause if possible
Consider specific causes based upon behavior
Confabulation
Multiple personalities
Special Challenges
The Patient with a Language Barrier
Extremely difficult to assess
Enlist friends or family to act as an interpreter
Use pre-established questions in the patients
language
Language Lines
Special Challenges
Intelligence & Literacy
Does the patient really understand your
questioning?
History may be inaccurate
Enlist friends or family
Can the patient actually read?
Read statements aloud to the patient
Special Challenges
The Patient with Sensory Deficits
Hearing Impaired
Does the patient read lips?
Face patient, close to good ear
Talk slowly and distinctly
Sign language?
Will a hearing aid help? Where is it?

Blindness
Voice and touch are critical
Establish relationship & trust early on
Culture differences or Misunderstand
Choosing to ask lots of
questions to obtain a
history WITHOUT
also directing initial
care or performing a
physical exam
Patients Impression
Not doing anything for
me
Why are we wasting
our time here?
Stop asking all these
silly questions
Culture differences or Misunderstand
Using a tone of voice
that sends the wrong
message
What is your
Problem TODAY?
Why did you call
911?
Patients Impression
He thinks I call EMS
for every little problem
I must have called 911
and was not supposed
to.
I think I am bothering
these nice people
Culture differences or Misunderstand
Lack of respect for
cultural, religious or
ethnic differences
Why do you people
use these home herbal
remedies?
You have enough
kids. You should
consider birth control
Patients Impression
This person thinks I
am a fool
She laughs at the
traditions of my culture
He does not respect my
personal decisions
Culture differences or Misunderstand
Poor choice of words
or using technical
terms
How many years has
your husband been
taking these ACE-
inhibitors?
Your wife is
experiencing
congestive heart
failure
Patients Impression
What the heck is he
talking about?
My wifes heart is
failing?!?! Has her
heart stopped yet?
Son, could you speak
English?
Summary
Obtaining the history guides the physical
exam
History-taking is accomplished along with
the physical exam and therapies
For emergent patients, the history-taking is
delayed or never actually obtained in the
prehospital setting
QUESTION?