History Taking

Good Communication
Helps you:
 understand the patient as a whole.
 build trust between you and your

patient.
 to agree on management goals.
 Poor Communication

 Leadsto patient dissatisfaction.

 Misunderstandings.
 Complaints.
 Improv
e
patient
satisfac
tion
Use
Effective Improve
time
doctor
more communic satisfact
effectiv ation ion
ely

Impro
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health
Talking With Patients
BASICS
 B A S

• Beginning • Active • Systemati

I Listening
C c inquiry
S
• Information • Context • Sharing
gathering
Beginning
 Setting
up:
-choose a quite, private space.
-close the curtains.
-respect their privacy.
-a doctor usually has around 12
minutes. As a student take AT LEAST 30
minutes.
 - arrange seating in a non-
confrontational way.

- Be professional in dress and

behavior to give a good first
impression.

-Introduce yourself. Shake hands if

culturally appropriate.
 Ask
the patient about the main problem
-How can I help you today?
-what brought you to the hospital?

 Listen ACTIVELY. You should pay attention,

look interested and allow the patient to talk.
 Ask OPEN questions. These encourage the

patient to talk.
Example
 Tellme more about your chest pain (open
question).
 Was your pain severe? (closed question)(yes or

no questions)

 Youstart with open questions, then to get the

details you ask closed questions afterwards.
 Haveempathy: which means
understanding what your patient is going
through.

Empathy ≠ Sympathy

 Sympathy is the expression of sorrow.

 Understand your patient’s context: you
should explore his life, where he lives,
what he does, his social supports and
culture. This helps improve the
doctor-patient relationship and helps
better with the management plan.
The History
1-The patient’s profile:

 Patient’sname , age , marital status ,

address , job.
 Source of history : patient , relative..
 Who took the history.
 Date & time of history taking.
 Source & time of referral/admission.
Example
 Mrs. Laila Ahmad Isam is a 34 year-old
married lady. She works as a teacher and
lives in al-Zarqa city. She was admitted on
the 2nd of July 2014 on 3:15 a.m. through
the ER. History was taken from the patient
herself by me ___ , 4th year medical student
on the 3rd of July 2014 at 10:00 a.m.
Presenting complaint:

 The major problem in the patient’s own

words with its duration.
 no medical terminology.
 Examples:

- Chest pain of 3-hour duration prior to

admission.
- dizziness of 30-minutes duration.
 Examples
Don’t use Use

dysphagia Difficulty in swallowing

dyspnea Shortness of breath

Seizure Abnormal movement/fit

angina Chest pain

History of present illness

 It is the analysis of the presenting

complaint .
Characteristics of pain (SOCRATES)

 Site
 Onset (sudden v.s. gradual)
 Character : sharp , dull , burning , stabbing,
crushing
 Radiation : local extension , referred
pain
Radiating pain
Referred pain
 Associated symptoms

 Timing : duration , course , pattern

-Duration: of each attack
- Course: evolution of pain during the
attack
-Pattern: e.g. every 15 minutes then none
at night
 Exacerbating & relieving factors : exertion ,
rest , posture , food , medications.

 Severity ( grade 0-10).

For any complaint also ask about
 Previous history of the same

complaint.
 Include other parts of history if

relevant (smoking in a cardiac or

respiratory presentation) , (family
history in a genetic disease ).
Review of Systems
General health :
 Well being , appetite , weight change , energy , sleep.

Cardiovascular system:
 Chest pain on exertion (angina)
 Shortness of breath :
 -Lying flat (orthopnoea)
 - At night (PND)
 Palpitations
 Pain in legs on walking (claudication)
 Lower limb swelling
Respiratory
 Shortness of breath
 Cough
 Wheezing
 Sputum production
 Blood in sputum (hemoptysis )
 Chest pain
GI
 Mouth (oral ulcers , dental problems)
 Difficulty swallowing (dysphagia)
 Painful swallowing (odynophagia)
 Nausea & vomiting
 Vomiting blood (hematemesis)
 Indigestion
 Heart burn
 abdominal pain
 Change in bowel habits
Genitourinary
 Pain passing urine (dysuria)
 Polyuria (passing large amounts)
 Frequency passing urine (at night called

nocturia)
 Blood in urine (hematuria)
 Incontinence (stress & urge)
For men:
 Prostatic symptoms:
Difficulty starting urination (hesitancy)
Poor stream
Terminal dribbling
Straining
 Urethral discharge

 Erectile dysfunction
Nervous System
 Headache
 Dizziness
 Faints
 Fits
 Altered sensation
 Weakness
 Visual & hearing disturbance
 Memory & concentration changes
Musculoskeletal
 Joint pain , stiffness & swelling
 Mobility
 falls
Endocrine
 Heat or cold intolerance
 Sweating
 Excessive thirst (polydepsia)
Past History
Past medical history:
 Chronic illness
 Previous hospital admissions
 History of blood transfusions
 Past procedures (endoscopies, bronchoscopies)
Past surgical history: (date, hospital, emergent or elective,
complications)
Past gynecological & obstetric history:
 Last menstrual period, age of menarch, # of pregnancies &
complications , types of deliveries & complications , menses (regularity ,
length , amount , pain) , OCP s, contraception.
Drug History
 Drug & other allergies (food , animal hair ,
pollens).
 Ask about prescribed drugs & over the

counter drugs (analgesics , vitamins,

laxatives, herbs). Write the generic name.
 Indication.
 Dose, frequency & duration of treatment.
 Side-effects.

compliance
Adherence
concordance
Family History
 Document illness and age of death in first
degree relatives(parents , siblings & children)
 If there is a suspicion of an inherited

disease ,go back for 3 generations & obtain

details of racial origins , consanguinity or
adoption
 Draw a pedigree chart.
Symbols
Male Female Deceased

Affected Carrier Mating

 consanguineous X-linked Recessive gene
mating

Dizygotic twins Propositus

Social History
 Occupation ; current & previous (exposure to
hazards : chemicals , dust , asbestos)
 Marital status , relationships , sexual history

 Type of home , size , owned or rented , stairs

 Hobbies , exercise , pets

 Smoking (cigarettes , cigars , pipe) duration & amount

expressed by pack years , passive smoking

 Alcohol , drug abuse

 Travel history & history of vaccination

Calculating pack years
1 pack of cigarettes = 20 cigarettes
# of cigarettes smoked X # of years
20

Example: (30 cigarettes X 10 years)/20 =

15 pack years.
 Report alcohol consumption in units.
 1 unit of alcohol= 8 grams of ethanol

= 10 ml of pure ethanol.
 1 unit of alcohol = ½ pint of beer (4%)

1 glass of wine
1 shot of spirits (40%)
 Calculate based on the ethanol
concentration.
 E.g., 4% alcohol = 40 ml pure ethanol/

liter= 4 units
Ending
 Summarize the findings
 Examine the patient
 Find a diagnosis or list differential

diagnoses.
Thank You