Principles of History Taking in Clinical Assessment

 
Principles of History Taking
 
Dr Thamer Bin Traiki
 
 
 
 
Prepare yourself to be a good physician
History Taking
 
 
A process of gathering information during
patient interview as part of patient clinical
assessment.
 
Importance
 
Obtaining  an accurate Hx is the critical 1
st
 step
in determining the etiology of a patient’s
problem .
 
A proper history and examination will get you
to your diagnosis almost 70% of the time .
Set Up
 
Your appearance is important (
wearing proper uniform, ie.
Lab coats, I.D., etc.
)
Your way of asking the Qs
See him walking in and not in the cubicle & allow
a relative to be there if the patient wants.
Provide a safe & private environment
Cont..
 
Introduce yourself
Greeting patient
By name
Shake hands
Avoid unfamiliar or demeaning terms
 
Be alert and pay him full attention
The way of getting the Hx
 
Ask open questions
Listen carefully
Take notes
Avoid interruption except
Special situations
 
 
History should be in the following order :
Personal data
Present complaint (c/o).
History of present complaint.
Systemic enquiry.
Past history: surgical, medical , drug history
Family history
Social history
 
P
e
r
s
o
n
a
l
 
D
a
t
a
 
Date and Time
Name & File number ( Medical record number)
Age
G
ender
Religion
Marital status
Occupation
Residency
Who gave the history?
Chief Complaint
 
Present complaint or problems  :
Symptom/Symptoms  that caused patient to seek
care and their duration .
In the patient’s own words
If multiple , list 
them in order of severity
 .
Chief complaint may be misleading
Problem may be more serious than the chief
complaint
History of the presenting Illness
 
Elaborate the symptom in medical terminology
Provides full clear, chronological details of the history
of the main problem/s .
Previous similar attack/s should be included
here .
What had been done for the patient if any
Elaborate the system involved.
Add any related symptoms .
Systemic Review
 
Negative symptoms are as important as
positive one.
 
You have to ask about them all, and keep
repeating them in each patient, to
memorize them well.
Neuro
 
Nervousness
Excitability
Tremor
Fainting attacks
Blackout
Loss of consciousness
Changes of smell, Vision
or hearing
 
Muscle weakness
Paralysis
Sensory disturbances
Paraesthesiae
Headaches
Change of behavior
Fits
 
Cardiovascular & Resp
 
Cough
Sputum
Haemoptysis
Dyspnoea
Hoarseness
Wheezing
Chest pain
Paroxysmal nocturnal
dyspnoea
 
Orthopnea
Palpations
Dizziness
Ankle swelling
Pain in limbs
Walking distance
Temperature and color
of hands and feet
 
GI
 
Appetite
Diet
Abnormal Taste
Dysphagia
Odynophagia
Regurgitation
Indigestion
Itching
 
Vomiting
Haematemses
Abdominal pain
Abdominal  Distension
Bowel habit
Melena
PR bleeding
Jaundice
 
Urogenital
 
Loin pain
Symptoms of uremia
Headache
Drowsiness
Fits
Visual disturbances
Vomiting
Edema of ankles, hands
of face
 
Lower urinary tract
symptoms ( LUTS)
Painful micturition
Polyuria
Color of urine
Hematuria
Male Infertility history
Sexual history
 
Musculoskeletal
 
Aches or Pain in muscles, bones and joints
Swelling of joints
Limitation of joints movements
Weakness
Disturbance of gait
 
Constitutional symptoms:
Weight loss/gain
Fever
Night sweats
Past Hx.
 
Childhood illnesses
Adult illnesses
Accidents and injuries
Surgeries or hospitalizations
Blood transfusion
Drugs : Insulin, Steroids and OCP
A
l
l
e
r
g
y
 
t
o
 
a
n
y
 
m
e
d
i
c
a
t
i
o
n
s
 
o
r
 
f
o
o
d
 
 
Family Hx
 
Health of immediate family
father , mother , 1
st
  degree relatives
HTN, DM , heart disease, contagious illnesses
Potential for hereditary diseases
Social Hx
 
Detailed marital status
Living accommodation
Occupation
Travel abroad
Leisure activity
Smoking
Drinking
Eating habits
Sensitive Topics
 
Alcohol or drug use
 
Physical abuse or violence
 
Sexual issues
Sensitive Topics Guidelines
 
Respect patient privacy
Be direct and firm
Avoid confrontation
Be nonjudgmental
Use appropriate language
Document carefully
Use patient’s words when possible
Special Challenge
 
Silence
Overly talkative patients
Patients with multiple
symptoms
Anxious patients
Limited intelligence
Crying
 
Anger and hostility
Intoxication
Depression
Confusing behavior or
histories
Developmental
disabilities
Language barrier
Cont..
 
False reassurance
May be tempting
Avoid early reassurance or “over reassurance”
Unless it can be provided with confidence
 
Common surgical symptoms
 
Pain
Lump
Ulcer
 
Pain Hx
 
1.
Site
2.
Time & mode of onset
3.
Duration
4.
Severity
5.
Nature ( Character)
6.
Progression of pain
7.
The end of pain
8.
Relieving factors
9.
E
x
a
g
g
e
r
a
t
i
n
g
 
(
E
x
a
c
e
r
b
a
t
i
n
g
)
 
f
a
c
t
o
r
s
10.
Radiation
11.
Cause
Visceral pain
 
Visceral peritoneum
 is innervated bilaterally by the
autonomic nervous system.
 
The bilateral innervation causes visceral pain to be midline,
vague, deep, dull, and poorly localized.
 
Visceral pain is 
triggered by inflammation, ischemia, and
geometric changes
 such as distention, traction, and pressure.
( usually the result of distention of a hollow viscus ).
 
Embryologic origin of the affected organ determines
the location of visceral pain in the abdominal
midline.
Foregut(stomach to the second portion of the duodenum, liver and biliary
tract, pancreas, spleen) , present as epigastric pain.
Midgut (second portion of the duodenum to the proximal two thirds of the
transverse colon) pain present as periumbilical pain.
 Hindgut (distal transverse colon to the anal verge) pain present with
suprapubic pain.
Parietal pain
 
Parietal peritoneum is innervated unilaterally via the spinal
somatic nerves that also supply the abdominal wall.
Unilateral innervation causes parietal pain to localize to one
or more abdominal quadrants .
Sharp, severe, and well localized.
The anterior and lateral abdominal wall is innervated from
vertebral segments T7 to L1, whereas the posterior abdominal
wall is from L2 to L5.
 
 
Parietal pain :
Triggered by :
Irritation of the parietal peritoneum by an inflammatory process
(e.g., chemical or bacterial).
Mechanical stimulation, such as a surgical incision.
Referred pain
 
Arises from a deep visceral structure but is
superficial at the presenting site 
i.e. pain felt at a remote
area from the diseased organ .
It results from 
central neural pathways
 that are
common to the somatic nerves and visceral organs
i.e. misinterpretation of visceral afferent impulse that cross
the nerve cells to the corresponding somatic dermatome
within the CNS .
 
 
 
Radiating pain 
is pain in remote area but in
continuity with the diseased organ .
Lump & Ulcer
 
When did u notice it ?
How did u notice it?
What are the associated symptoms ?
Persistence ( does it ever disappear ?)
Progression ( change in its size )
Any other lump currently or previously
What do u think the cause ?
 
 
 
Questions
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History taking is a crucial process in patient assessment, aiding in determining the etiology of medical issues. Obtaining an accurate history through proper questioning, active listening, and maintaining a professional appearance is vital for making accurate diagnoses. The history should follow a structured order including personal data, present complaint, history of present complaint, systemic inquiry, past medical history, family history, and social history. By adhering to principles such as establishing rapport, asking open-ended questions, and paying full attention to the patient, healthcare providers can effectively gather essential information for diagnosis and treatment planning.


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  1. Principles of History Taking Dr Thamer Bin Traiki

  2. Prepare yourself to be a good physician

  3. History Taking A process of gathering information during patient interview as part of patient clinical assessment.

  4. Importance Obtaining an accurate Hx is the critical 1ststep in determining the etiology of a patient s problem . A proper history and examination will get you to your diagnosis almost 70% of the time .

  5. Set Up Your appearance is important (wearing proper uniform, ie. Lab coats, I.D., etc.) Your way of asking the Qs See him walking in and not in the cubicle & allow a relative to be there if the patient wants. Provide a safe & private environment

  6. Cont.. Introduce yourself Greeting patient By name Shake hands Avoid unfamiliar or demeaning terms Be alert and pay him full attention

  7. The way of getting the Hx Ask open questions Listen carefully Take notes Avoid interruption except Special situations

  8. History should be in the following order : Personal data Present complaint (c/o). History of present complaint. Systemic enquiry. Past history: surgical, medical , drug history Family history Social history

  9. Personal Data Date and Time Name & File number ( Medical record number) Age Gender Religion Marital status Occupation Residency Who gave the history?

  10. Chief Complaint Present complaint or problems : Symptom/Symptoms that caused patient to seek care and their duration . In the patient s own words If multiple , list them in order of severity . Chief complaint may be misleading Problem may be more serious than the chief complaint

  11. History of the presenting Illness Elaborate the symptom in medical terminology Provides full clear, chronological details of the history of the main problem/s . Previous similar attack/s should be included here . What had been done for the patient if any Elaborate the system involved. Add any related symptoms .

  12. Systemic Review Negative symptoms are as important as positive one. You have to ask about them all, and keep repeating them in each patient, to memorize them well.

  13. Neuro Nervousness Excitability Tremor Fainting attacks Blackout Loss of consciousness Changes of smell, Vision or hearing Muscle weakness Paralysis Sensory disturbances Paraesthesiae Headaches Change of behavior Fits

  14. Cardiovascular & Resp Cough Sputum Haemoptysis Dyspnoea Hoarseness Wheezing Chest pain Paroxysmal nocturnal dyspnoea Orthopnea Palpations Dizziness Ankle swelling Pain in limbs Walking distance Temperature and color of hands and feet

  15. GI Appetite Diet Abnormal Taste Dysphagia Odynophagia Regurgitation Indigestion Itching Vomiting Haematemses Abdominal pain Abdominal Distension Bowel habit Melena PR bleeding Jaundice

  16. Urogenital Loin pain Symptoms of uremia Headache Drowsiness Fits Visual disturbances Vomiting Edema of ankles, hands of face Lower urinary tract symptoms ( LUTS) Painful micturition Polyuria Color of urine Hematuria Male Infertility history Sexual history

  17. Musculoskeletal Aches or Pain in muscles, bones and joints Swelling of joints Limitation of joints movements Weakness Disturbance of gait

  18. Constitutional symptoms: Weight loss/gain Fever Night sweats

  19. Past Hx. Childhood illnesses Adult illnesses Accidents and injuries Surgeries or hospitalizations Blood transfusion Drugs : Insulin, Steroids and OCP Allergy to any medications or food

  20. Family Hx Health of immediate family father , mother , 1stdegree relatives HTN, DM , heart disease, contagious illnesses Potential for hereditary diseases

  21. Social Hx Detailed marital status Living accommodation Occupation Travel abroad Leisure activity Smoking Drinking Eating habits

  22. Sensitive Topics Alcohol or drug use Physical abuse or violence Sexual issues

  23. Sensitive Topics Guidelines Respect patient privacy Be direct and firm Avoid confrontation Be nonjudgmental Use appropriate language Document carefully Use patient s words when possible

  24. Special Challenge Silence Overly talkative patients Patients with multiple symptoms Anxious patients Limited intelligence Crying Anger and hostility Intoxication Depression Confusing behavior or histories Developmental disabilities Language barrier

  25. Cont.. False reassurance May be tempting Avoid early reassurance or over reassurance Unless it can be provided with confidence

  26. Common surgical symptoms Pain Lump Ulcer

  27. Pain Hx 1. Site 2. Time & mode of onset 3. Duration 4. Severity 5. Nature ( Character) 6. Progression of pain 7. The end of pain 8. Relieving factors 9. Exaggerating (Exacerbating) factors 10.Radiation 11.Cause

  28. Visceral pain Visceral peritoneum is innervated bilaterally by the autonomic nervous system. The bilateral innervation causes visceral pain to be midline, vague, deep, dull, and poorly localized. Visceral pain is triggered by inflammation, ischemia, and geometric changes such as distention, traction, and pressure. ( usually the result of distention of a hollow viscus ).

  29. Embryologic origin of the affected organ determines the location of visceral pain in the abdominal midline. Foregut(stomach to the second portion of the duodenum, liver and biliary tract, pancreas, spleen) , present as epigastric pain. Midgut (second portion of the duodenum to the proximal two thirds of the transverse colon) pain present as periumbilical pain. Hindgut (distal transverse colon to the anal verge) pain present with suprapubic pain.

  30. Parietal pain Parietal peritoneum is innervated unilaterally via the spinal somatic nerves that also supply the abdominal wall. Unilateral innervation causes parietal pain to localize to one or more abdominal quadrants . Sharp, severe, and well localized. The anterior and lateral abdominal wall is innervated from vertebral segments T7 to L1, whereas the posterior abdominal wall is from L2 to L5.

  31. Parietal pain : Triggered by : Irritation of the parietal peritoneum by an inflammatory process (e.g., chemical or bacterial). Mechanical stimulation, such as a surgical incision.

  32. Referred pain Arises from a deep visceral structure but is superficial at the presenting site i.e. pain felt at a remote area from the diseased organ . It results from central neural pathways that are common to the somatic nerves and visceral organs i.e. misinterpretation of visceral afferent impulse that cross the nerve cells to the corresponding somatic dermatome within the CNS .

  33. Radiating pain is pain in remote area but in continuity with the diseased organ .

  34. Lump & Ulcer When did u notice it ? How did u notice it? What are the associated symptoms ? Persistence ( does it ever disappear ?) Progression ( change in its size ) Any other lump currently or previously What do u think the cause ?

  35. Questions

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