Art of history taking,Art of history taking

Àbout history taking

1. ART OF HISTORY TAKING By Dr Seran MBBS NAAM hospital

2. HISTORY TAKING

3. Hutchison’s Clinical Methods (25th edition): “Taking a history is the art of obtaining information from the patient that defines their problems, clarifies the sequence of events, and provides insight into possible causes of disease, while establishing rapport and trust.”

4. Builds rapport and trust between doctor and patient . Ensures correct identification and prevents mix-ups. G ives a professional and respectful tone to the encounter . May hint at cultural or regional background (useful for social and genetic clues).

5. Essential identifying data — age is recorded at the start of history taking. A ids diagnosis — many diseases are age-specific (e.g., congenital in infants, rheumatic fever in children, cancer in elderly). Guides differential diagnosis — helps narrow likely conditions based on age group. I nfluences disease presentation — same illness may appear differently with age . D etermines treatment & drug dosage — age affects metabolism and response. E ffects prognosis — recovery and outcomes vary with age. Important for screening — certain tests (like mammogram, colonoscopy) are age-based. Supports preventive care — helps plan vaccinations and health advice.

6. Certain diseases are sex-specific (e.g., carcinoma cervix in females, prostate disorders in males). Some diseases are more common in one sex (e.g., autoimmune diseases in females, gout in males). Hormonal factors influence disease pattern and presentation. Guides preventive screening (e.g., breast, cervical, prostate).

7. Address Religion Helps identify geographical or environmental diseases (e.g., malaria, filariasis ). Gives clue to endemic and epidemic diseases. Provides social and economic background (urban vs. rural living conditions). Influences health beliefs & practicesAffects diet & lifestyleGuides Consent & decision making Support patient-provider relationship Provides psychological & social support

8. Occupation Socio-economic status Reveals occupational diseases (e.g., silicosis in miners, asbestosis in factory workers)
Identifies exposure to chemicals, dust, radiation, or noise
Indicates work-related stress and lifestyle.
Helps assess socioeconomic status. Influences disease risk and exposure
SES affects living conditions, occupational exposures, nutrition, hygiene, housing, crowding, access to clean water, etc.—all of which can predispose to certain diseases or alter clinical course. For example, low income or poor housing may mean higher risk of infectious diseases, or exposure to environmental toxins.

9. Chief complaint “The chief complaint is the symptom or problem that prompts the patient to seek medical attention, stated in the patient’s own words.” Always document in the patient’s own words.

Helps focus the history and examination.

Usually recorded at the beginning of the medical history.

10. History of presenting illness The History of Presenting Illness (HPI) is a detailed, chronological description of the development of the patient’s current illness from the onset of symptoms to the present, including factors that aggravate, relieve, or modify the symptoms. S – Site (location of symptom)

O – Onset (when and how it started)

C – Character (type of symptom: sharp, dull, burning)

R – Radiation (does it spread anywhere)

A – Associated symptoms (any other symptoms with it)

T – Timing (duration, frequency)

E – Exacerbating/relieving factors

S – Severity (intensity, e.g., scale of 1–10)

11. Past history “Past history includes all illnesses, operations, injuries, and hospital admissions the patient has had in the past, which may have a bearing on the present complaint.” Previous Illnesses:Chronic illnesses (e.g., diabetes, hypertension, asthma)
Surgeries and Hospitalizations
Accidents or Injury
Childhood Diseases
Allergies Immunization/Vaccination History
Blood Transfusions or Major Treatments
Obstetric/ Gynecological History (for females)
Pregnancy, deliveries, abortions, menstrual history

12. Personal history Diet and nutrition

Appetite and sleep

Bowel and bladder habits

Addictions (alcohol, smoking, drugs)

Marital history

For all reproductive age group women LMP should be asked

13. Family history Family members with similar symptoms or diseases.Pattern of inheritance (dominant, recessive, etc.). Any sudden unexplained deaths in the family (may indicate cardiac arrhythmias, epilepsy). Lifestyle patterns shared in the family (diet, smoking, alcohol). H/O Diabetes mellitus,Hypertension,Coronary artery disease (CAD) or stroke,Tuberculosis,Asthma,Epilepsy,Psychiatric illness,Cancer (especially breast, colon, or prostate cancer), H/O Thalassemia, Hemophilia , Sickle cell disease.
H/O Muscular dystrophy, Cystic fibrosis.
H/O Congenital malformations or metabolic disorders.

14. Medication history Note name, dose, frequency, and duration of all prescribed drugs.

Include over-the-counter (OTC) and herbal / traditional medicines.

Ask about drug allergies or adverse reactions.

Identify drug compliance (whether the patient takes medication regularly).

Important to detect drug-induced diseases (e.g., NSAID gastritis, steroid diabetes).

Helps prevent dangerous drug interactions and contraindications. To avoid over dosage

15. General examination Built and nourishment Pallor Icterus Clubbing Cyanosis Lymphadenopathy Peripheral edema GCS Skin turgor

16. Vitals Pulse rate Blood pressure Respiratory rate Temperature SpO2 Capillary refill time

17. Systemic Examination

18. Respiratory system Method Purpose / What to Assess Findings / Examples Inspection Tracheal position, Observe chest shape and movement, respiratory effort Barrel chest, use of accessory muscles, cyanosis, retractions Palpation Confirm what are all seen in inspection Tracheal position, Assess chest expansion, tenderness, and tactile fremitus Reduced expansion, increased/decreased fremitus, tenderness Percussion Evaluate underlying lung tissue and air/fluid presence Resonant (normal), dull (consolidation/effusion), hyperresonant (emphysema/pneumothorax) Auscultation Listen to breath sounds and added sounds& Bowel sounds Normal vesicular, bronchial, crackles, wheeze, pleural rub, Hiatal hernia

19. Cardiovascular system Method Purpose / What to Assess Findings / Examples Inspection Observe chest, precordium, and general appearance Visible pulsations, cyanosis, scars, abnormal chest shape Palpation Assess precordial movement, thrills, and pulses Heaves, thrills, apex beat location and character, radial pulse abnormalities Percussion Evaluate heart size and borders Normal cardiac dullness, cardiomegaly (enlarged borders) Auscultation Listen to heart sounds and murmurs S1, S2, extra heart sounds (S3/S4), murmurs, rubs, gallops

20. Abdominal examination Method Purpose / What to Assess Findings / Examples Inspection Observe abdomen for shape, scars, distension, skin changes Distension, surgical scars, striae, visible veins, umbilical hernia Palpation Assess tenderness, Palpableorganomegaly,masses Guarding, Rigidity Tenderness, hepatomegaly, splenomegaly, palpable masses, rigidity Percussion Evaluate organ size and presence of fluid or air Tympany (gas), dullness (fluid or organ), shifting dullness (ascites) Auscultation Listen to bowel and vascular sounds Bowel sounds (normal, hyperactive, hypoactive, absent), bruits, friction rubs

21. Central nervous system Higher mental functions a. Consciousness b. Orientation – time, place, person c. Memory – short, place, person d. Intelligence e. Speech f. Handedness g. Emotion Motor system a. Bulk b. Tone c. Power d. Coordination e. Gait f. Involuntary movements g. Reflexes

22. Sensory system Spinothalamic sensations Touch P ain Temperature Posterior column sensations Vibration sense Joint sense P osition sense Romberg s sign Cortical sensations Tactile localization Tactil e discrimination Stereognosis Graphesthesia Autonomic nervous system Skin Color Palpate extremities Iodine–Starch Test Pupillary Autonomic Function Orthostatic hypotension Cerebellum Dysmetria Nystagmus Ataxia of Gait & Limbs Dysdiadochokinesia Rebound phenomenon pointing test pendular knee jerk

23. Reference Hutchison 25 th edition Macleod’s clinical examination 14 th edition

24. Thank you