History taking

The forgotten art of History taking in Medicine.

1. History taking Dr Anwar H. Siddiqui

2. What is History taking ? It is a process by which information is gained by a physician by asking specific questions to the patient with the aim of obtaining information useful in formulating a diagnosis and providing medical care to the patient

3. I m p o r t a n c e o f Hi s t o r y T a k i ng ? O b t a ini n g a n ac c u r a te h i s t o ry i s the c riti c al f i r s t s t e p i n d e t e r m i n i n g t h e et i ol ogy o f a p a ti e n t 's illn e s s. Diagnosis in medicine is based on Clinical history Physical Examination Investigations

4. A la r g e p e r c e n t a ge o f t h e time ( 70 % ) , y ou w i ll ac t u a ll y b e a ble m a k e a d i a g nos i s b a s e d on t h e h i s t ory a l on e .

5. How to take a history ? “ Al w ays l i s t en t o the patie n t th e y mig h t b e t el l ing yo u the diagnosis ” . (S ir W illi am Osle r 1849 - 1919) The basis of a true history is good communication between doctor and patient. It takes practice, patience, understanding and concentration.

6. Approach to history taking Your look is important Your dressing

7. Introduce your self and create a rapport Approach to history taking

8. Be alert and pay full attention Approach to history taking

9. En s u r e c onse n t ha s bee n g aine d . Mai n t ain pri v acy and digni t y . Ensure the patient is as comfortable as possible Summarise each stage of the history taking process. Involve the patient in the history taking process Approach to history taking

10. “ If i n a bad mood or di s trac t ed during the c onsul t ation , yo u c a n end u p mak i n g a hi s t o r y rather t ha n t aki n g a h i s t o r y ” .

11. Components of History taking Patient ’ s profile Chief complaint History of the present illness Past medical history Family history Socioeconomic history System Review

12. 1. Patients profile Date and Time Name Age Sex Religion Marital status Occupation Address Who gave the history?

13. 2. Chief complaint The main reason for which the patient is trying to seek medical help by visiting the physician. Usually a single symptoms, occasionally more than one complaints eg : fever, headache, pain, etc The patient describe the problem in their own words. It should be recorded in patients own words. The complain should be recorded with their onset duration

14. How to ask for chief complaint? What brings your here? How can I help you? What seems to be the problem? If there is more than one complaint, it should be written according to chronological order 2. Chief complaint

15. 2. Chief complaint Example, Fever-2 weeks, Productive cough-1 week, Vomiting -2 days, Fatigue-1day,

16. 3. History of the present illness Elaborate on the chief complaint in detail Ask relevant associated symptoms Gain as much information you can about the specific complaint. Lead the conversation by asking questions. Always start with an open ended question and take the time to listen to the patient’s ‘story’. Once the patient has completed their narrative then closed questions can be asked to clarify . Leading question are to be avoided.

17. Open questions allow patients to express their own thoughts and feelings, e.g. 'Is there anything else that you want to mention?’ Closed questions are requests for factual information, e.g. 'When did this pain start?’ Leading questions are based on your own assumptions that lead the patient to the answer you want to hear. 3. History of the present illness

18. In details of present problem with- time of onset/ mode of evolution/ any investigation;treatment &outcome/any associated +’ve or -’ve symptoms. Avoid medical terminology and make use of a descriptive language that is familiar to patients Sequential presentation Always relay story in days before admission Narrate in details 3. History of the present illness

19. Tips to gather information: 3. History of the present illness S O C R A T E S S i t e O ns e t Cha r ac t er R adi a t i o n (o f pai n o r di s c o m f ort) Al l e vi a t i n g f ac t o r s T im i ng E x acerb a t i n g f ac t o r s S e v eri t y (

20. The patient was apparently well 1 w e e k be f or e t h e a d m i ss i on when the p a t i e n t f e l l w hi l e g a r d eni ng a n d c u t hi s f oo t w it h a s t o n e . B y that eve n i ng , t h e f oo t b ec a me s w o ll e n a n d p a ti ent w a s un a b l e t o w a l k. N e x t d a y pa t i e n t a tt e nd e d a private clinic where t h e y g ave him s o me o r al medicines . The patient do e s n ’ t kn ow t h e n ame of the medicines given but says that he was told the medicine would suppress his leg pains .however T h e r e was no improvement in h i s c ond iti o n . T w o d a y s p r i o r t o a d mi ss i on in JNMC , t h e swelling in the foot s t a r t e d t o d i s c h a r ge p us. The r e i s h i g h f e v e r a n d r i go rs w it h n a u s ea a n d vo mit i n g. 3. History of the present illness

21. 4. Past medical history Any history of similar complaint in the past Other medical problems the patient has or had Any chronic disease present like hypertension, diabetes etc Past hospitalizations and past surgeries Medications if any taken in the past (dosage and duration) Allergies Pediatric: Birth history, Developmental Milestones, Immunizations Gyane /Obstetric history if female

22. 5. Family history It is important to establish whether there are any genetically transmitted diseases within families Any illness run in thefamily ? Similar history in the family, Parents and siblings suffering with any chronic illness, Parents if died, how old and what they died of You should be able to collect relevant family history depending upon the present illness. Example, Patient has come due anemia , Try to rule out sickle cell, thalasemia / G6PD deficiency

23. 6. Socioeconomic history Smoking history - amount, duration and type. Drinking history - amount, duration and type Any drug addiction Sexual history if suspected STI Occupation, social and education background, financial situation

24. 7. S ystem R ev i e w Ca r d i ovasc u lar • Che s t p a i n • P aroxysma l No c turn a l Dyspno e a • Or t hopno e a • Shor t O f Bre a t h • Cough / s put u m ( • P al pit a t ions • Cya n os is R e s p i rator y Sy s t em • Cough(produ c t i v e / dry) • Spu tum ( c ol our, a mount , s mel l) • H ae mop t ys i s • Ch e s t p a i n • SO B /D y spno e a • T a c h y p n o e a • Ho arse n e s s • Whe e zi ng G e n e ral • Wea k n e ss • F at igue • Anor e x i a • Ch a nge of w ei ght • F e v er • L um ps • N i ght s w e a ts G a s t r o i n t e s t in a l /A li me nta ry • App et ite ( a norex i a / w e ight ch a nge ) • D ie t • N ausea /vom i t ing • R e gurgi t at i on/h e art burn/f l a t u l en c e • D i ff i cu l t y in sw al l owing • Abdo mi nal p a in/d i s t ensi on • Ch a nge of bowe l h a bit • H ae ma t eme s is , m e l a ena • J a und i ce

25. U ri n ar y Sy s t em • Fr e qu e nc y • Dy s u r i a • Urg e n cy • H e s i t an cy • T erm i nal dr i bbli n g • No ct uria • B a ck/ l oi n pa in • In c ontin e nce • Ch a rac t e r of u r ine : col o r / a mount (polyur i a ) & t i mi ng • F e v er G e n i tal s y s t em • P ai n/ di s c om f o r t/ i t ch ing • D i s c h a rge • Unus u a l bl e edi n g N e r vous Sys t em • V i su a l / Sm e ll / Ta s t e /H ea ring / S pe e c h • H e a d a c he • F i t s / F a int s / B l a ck ou t s / l o s s of c o n s c iou s n e s s( L O C) • Mu s c le w e a k n e s s / n u mbne ss / pa r alysi s • Abnor ma l s en s a ti on • Cha n g e o f b e hav i o u r or p s y c he M us c u l os k e letal Syst em • P ain – m uscl e , bon e, jo i nt • Sw e l l i ng • Weakn e s s / movement • D e form i t ie s 7. System review

26. Now you’ve got your information Give a Summary Ask if you’ve understood the information correctly Ask if there is any other information that the patient wants you to know Advise what your plan would be Check with the patient that they are in agreement with your plan