History taking

1. History taking

2. Definition • A case history is defined as a planned professional conversation that enables the patient to communicate his/her symptoms, feeling and fear to the clinician so as to obtain an insight into the nature of the patients illness and his/her attitude to them

3. Why history taking is important • To establish a diagnosis • Detect medical problems • Evaluate other systemic problems • Discovery of communicable diseases • Management of emergencies • For effective treatment plan

4. Diagnosis occurs through • Taking and recording case history • Physical examination • Request relevant investigations • Establish a diagnosis • Outline management step • Prognosis and clinical evaluation of the most probable outcome of therapy

5. Tasks to be achieved by physician in history taking 1. Build a relationship with the patient. 2. Learn about the patient as a person. 3. Help the patient with the emotional aspects of the illness. 4. Help the patient learn about health, illness and health care options. 5. Choose an appropriate course of action with the patient.

6. 6. Help the patient plan and carry out the chosen action. 7. Understand the impact of the illness on the patient and his/her family. 8. Define the patient’s understanding of his/her illness ndattitudes in regard to evaluation and treatment

7. Before start history taking • Introduce Yourself to the Patient • Put the Patient at Ease • Establish eye contact • Your approach to the patient should be gentle, sympathetic, friendly and confident • Listen to the patients concerns and then ask questions about aspects that remain deficient

8. If interruption is necessary it should be timed and planned • Encourage the patient to give details of his symptoms and don’t use of medical terms • Avoid writing when the patient is talking, this will give the impression that you are not listening • Write the history in order and avoid jargon

9. Sequence of history taking • Personal data • Chief complain • History of presenting illness • Systemic review • Past medical history • Family history • Social history • Drug history

10. a. Personal data • Name: • Identification • For communication • For rapport with the patient • Record maintenance • Age: • Certain disease occurs at different age groups e.g. measles is common in children. Myocardial infarction is common in old patients

11. Gender: • Some diseases occurs more common in one particular sex. E.g. SLE is more common in female • Address: • For future contact • Give view of socioeconomic status • Prevalence of the disease • Occupation: • Assess the socioeconomic status of the patient • Predilection of disease in different occupations e.g. hepatitis in nurses and dentist, lung fibrosis in industrial workers • Date of admission

12. Chief complain • The chief complain is established by asking the patients to describe the problem they seek medical help for. • It is recorded in the patients own words and no medical or technical language is used

13. It is recorded in a chronological order of their appearance • Chest pain / 2 months • Fever / 1month • Vomiting / 2 days • The chief complain aids in the diagnosis and treatment planning and should be given the first priority

14. History of presenting illness • Initially the patient may not volunteer the detailed history of the problem so the examiner has to elicit additional information by asking closed ended questions • Analyze each complain in details

15. Ask about other relevant symptoms to the system involved • Patients tends to forget less severe symptoms. In order to make sure that no aspect of the patient’s illness is missed it is recommended that you should ask about all cardinal symptoms of each systems.

16. Systems Review General wellbeing: • weight (gained, lost or static), appetite (good, poor), fever (duration, grade, pattern, reliving and aggravating factors, associated with chills, rigor, sweats. headache), fatigue

17. NS: • loss of consciousness, headache (Onset, Site, timing, Continuous/ intermittent, Nature, Duration, Severity, Reliving and aggravating factors, Progression, Associated features) , dizziness, weakness (onset, site, course, complete or incomplete paralysis, static or progressive),

18. convulsion (frequency, aura, loss of consciousness, generalized/ localized, tonic clonic/rigidity, tongue biting, urinary and fecal incontinence, fall/trauma, duration of the attack, after the attack the patient had any symptoms e.g. headache, paralysis, went to deep sleep, do the attacks come during sleep), • Tremor, sensory loss, numbness, tingling sensation, symptoms related to cranial nerve palsy

19. Cardiopulmonary: • Cough (duration, frequency, more at day/night, dry or productive, sputum “amount, color, smell, blood), chest pain (Onset, Site, timing, Continuous/ intermittent, Nature, Duration, Severity, Radiation, Reliving and aggravating factors, Progression, Associated features), SOB (grade), PND, orthopnia, palpitation (duration, awareness, onset, associated symptoms) , haemoptysis, wheeze, syncope

20. GIT: • indigestion (dyspepsia), gas, heartburn, nausea, vomiting (duration, frequency, projectile or not, amount, color, smell, content of the vomitus, haematamesis, relation to food), abdominal pain (Onset, Site, timing, Continuous/ intermittent, Nature, Duration, Severity, Radiation, Reliving and aggravating factors, Progression, Associated features), abdominal distension (site, generalized/localized progression)

21. hematemesis, melena, stool, constipation (frequency, duration, normal bowel habits, blood, alternating bowel habits, eating habits), diarrhea (duration, frequency, amount, consistency, blood or mucus, tenesmus, severity, associated symptoms), jaundice, hematochezia.

22. GU: • loin pain (Onset, Site, timing, Continuous/ intermittent, Nature, Duration, Severity, Radiation, Reliving and aggravating factors, Progression, Associated features), frequency (nocturia, polyuria) prostatism (urgency, hesitance, dripping, urinary retention), incontinence, dysuria, hematuria. Menstrual cycle in female

23. Musculoskeletal: • Rashes, itching, changes in hair, bruising, joint pain (joints affected, sequence of involvement, joint swelling, relation with movement), swelling, morning stiffness, lower limb edema (site, progression)

24. Past medical history • Past history of similar condition • Hospitalization , surgeries, blood transfusion • All disease suffered by the patient should be recorded in chronological order • The patient should be assessed by direct open and closed ended questions

25. Whether he is suffered from any major systemic illness (diabetes, hypertension, heart disease, asthma, epilepsy) • Ask specifically about certain disease relevant to the patients history • Ask about history of contact especially in infectious diseases

26. Family history • The health of the entire family, living and dead with particular attention to the possible genetic and environmental determinants of disease • Family history of similar condition • Major disease (diabetes, hypertension, heart disease, asthma, epilepsy)

27. Social history • Marital status • Smoking • Alcohol • Financial support • Availability of support

28. Impact of the disease: ability to work, coping with daily activities, personal relationship • Housing: flat. Stairs, modification, pets • Hobbies • Travel • Immunization and prophylaxis

29. Drug history • If the patient does not remember the name of medications ask if he has any with him now or old prescription • Write down the name, dosage, duration of therapy, compliance, • Long term medication • Current medications • Adverse reactions • allergies