Principles of history taking. Reviewing the Chart: The medical chart give you valuable information about past diagnosis and treatment You should look

Principles ofPrinciples of historyhistory taking taking

Reviewing the Chart:Reviewing the Chart:

The medical chart give you valuable The medical chart give you valuable information about past diagnosis and information about past diagnosis and treatmenttreatment

You should look at the identifying data You should look at the identifying data (age, gender, address, (age, gender, address, marital status, marital status, health insurance, the medication list, the health insurance, the medication list, the documentation of allergies)documentation of allergies)

Clinician’s BehaviorsClinician’s Behaviors

As you observe the patient throught the As you observe the patient throught the interview, the patient will be watching youinterview, the patient will be watching you

You should be sensitive to those messages You should be sensitive to those messages and manage them as well as you canand manage them as well as you can

Posture, gesture, eye contact, and words can Posture, gesture, eye contact, and words can express interest, attention, acceptance, and express interest, attention, acceptance, and understandingunderstanding

The skilled interviewer seems calm and The skilled interviewer seems calm and unhurried, even when time is limitedunhurried, even when time is limited

Clinician’s AppearanceClinician’s Appearance

Cleanliness, neatness and a name tag are reassuring to the patient.

Remember that you want the patient to trust you

Note takingNote taking

You need to write down much of what you learn in a health history

The EnviromentThe Enviroment Make the setting as private as possible

Learning about the Patient’s iIlnessLearning about the Patient’s iIlness

Greeting the PatientGreeting the Patient Greet the patient and introduce yourself Greet the patient and introduce yourself

by nameby name If this is the first contact, clarify your If this is the first contact, clarify your

role, such as stating your status as a role, such as stating your status as a student and explaining your relation to student and explaining your relation to the patient’s carethe patient’s care

When other individuals are present, ask When other individuals are present, ask the permission of the patient to conduct the permission of the patient to conduct the interview in front of themthe interview in front of them

The Patient’s ComfortThe Patient’s Comfort

Be alert to the patient’s comfort

Comprehensive historyComprehensive history

Data and time of history: the date is Data and time of history: the date is importantimportant

Identifying data: including age, gender, Identifying data: including age, gender, maritual status and occupationmaritual status and occupation

Source of history: such as patient, family, Source of history: such as patient, family, friend, officer, consultant, medical recordfriend, officer, consultant, medical record

Chief complaintsChief complaints


Present illnesPresent illnes Current medication: including dose and Current medication: including dose and

frequency of usefrequency of use AllergiesAllergies Past historyPast history Childhood illnesses: such as measles, Childhood illnesses: such as measles,

rubella, mumps, whooping cough, chicken rubella, mumps, whooping cough, chicken pox, rheumatic fever, poliopox, rheumatic fever, polio


Adult illnesses:Adult illnesses:

MedicalMedical

1.1. Diabetes mellitusDiabetes mellitus

2.2. HypertensionHypertension

3.3. HepatitisHepatitis

4.4. AsthmaAsthma

5.5. HIVHIV


Adult illnesses:Adult illnesses:

Surgical: include dates, indication, outcomeSurgical: include dates, indication, outcome

Obstetric/ Gynecologic: inculde obstetric Obstetric/ Gynecologic: inculde obstetric history, menstruation history, birth control, history, menstruation history, birth control, number and gender of partners, at-risk number and gender of partners, at-risk practisespractises

Psychiatric: include dates, diagnosis, Psychiatric: include dates, diagnosis, hospitalisations, treatmenthospitalisations, treatment

Current health statusCurrent health status

Tobacco (type used, amount and duration of Tobacco (type used, amount and duration of use)use)

Alcohol (type used, amount and duration of Alcohol (type used, amount and duration of use)use)

Drugs (type used, amount and duration of Drugs (type used, amount and duration of use)use)

Current health statusCurrent health status

Exercise and dietExercise and diet Immunisations: Immunisations: 1.1. TetanusTetanus2.2. PertussisPertussis3.3. DiphteriaDiphteria4.4. PolioPolio5.5. MeaslesMeasles6.6. RubellaRubella7.7. MumpsMumps8.8. InfluenzaInfluenza9.9. Hepatitis BHepatitis B

Family historyFamily history

Age and health, or age and couse of death of Age and health, or age and couse of death of each immediate family members (parents,each immediate family members (parents,

siblings, spouse, and children)siblings, spouse, and children)

Date of grandparents and grandchildren Date of grandparents and grandchildren may also be usefulmay also be useful


Diabetes mellitusDiabetes mellitus Heart diseaseHeart disease HypercholeterolemiaHypercholeterolemia High blood pressureHigh blood pressure StrokeStroke Kidney diseasesKidney diseases


ArthritisArthritis AnemiaAnemia AllergiesAllergies AsthmaAsthma HeadachesHeadaches Mental illnessMental illness


TuberculosisTuberculosis CancerCancer DrugsDrugs EpilepsyEpilepsy

Personal and Social HistoryPersonal and Social History

Occupation and educationOccupation and education

Home situationHome situation

Daily lifeDaily life

Leisure activites/hobbiesLeisure activites/hobbies

Present illnessPresent illness

The principal symptoms should be discribed in The principal symptoms should be discribed in terms of:terms of:

1.1. LocationLocation2.2. QualityQuality3.3. Quantity and severityQuantity and severity4.4. TimingTiming5.5. Factors that have aggrevated or relievedFactors that have aggrevated or relieved

themthem

Review of systemsReview of systems

General:General: Weight, recent weight changeWeight, recent weight change WeaknessWeakness FatiqueFatique FeverFever


Skin:Skin: Rashes, Rashes, lumps,lumps, sores, sores, itching,itching, dryness,dryness, color changecolor change Hair and nails changesHair and nails changes


HeadHead: headache, head injury, dizziness: headache, head injury, dizziness EyesEyes: vision, glasses, contact lenses, pain, : vision, glasses, contact lenses, pain,

redness, dryness, double vision, spots, redness, dryness, double vision, spots, flashing lights, glaucoma, cataractaflashing lights, glaucoma, cataracta

EarsEars: hearing, vertigo: hearing, vertigo Nose an sinusesNose an sinuses: frequent cold, nasal : frequent cold, nasal

stuffiness, hay fever, sinus troublestuffiness, hay fever, sinus trouble


Mouth and throutMouth and throut: condition of teeth, gums, bleeding : condition of teeth, gums, bleeding gums,sore tonque, dry mouth, frequnt sore throats, gums,sore tonque, dry mouth, frequnt sore throats, hoursenesshourseness

NeckNeck: lumps, „swollen glands”,goiter pain: lumps, „swollen glands”,goiter pain

BreastBreast: lumps, pain and discomfort: lumps, pain and discomfort

RespiratoryRespiratory: cough, sputum (color quantity): cough, sputum (color quantity)hemoptysis, dyspnea, wheezing, asthma, bronchitis, hemoptysis, dyspnea, wheezing, asthma, bronchitis, emphysema, pneumonia, tuberculosisemphysema, pneumonia, tuberculosis, ,


CardiacCardiac: : heart trouble, heart trouble, high blood pressure,high blood pressure, rheumatic fever,rheumatic fever, heart murmurs, heart murmurs, chest pain or discomfort,chest pain or discomfort, palpitations, dyspnoe, orthopnoe, palpitations, dyspnoe, orthopnoe,

paroxysmal nocturnal dyspnoe, edemaparoxysmal nocturnal dyspnoe, edema


GastrointestinalGastrointestinal:: Trouble swallowingTrouble swallowing HeartburnHeartburn AppetiteAppetite NauseaNausea VomitingVomiting RegurgitationRegurgitation Vomiting of bloodVomiting of blood


GastrointestinalGastrointestinal::Bowel movementsBowel movementsColor and size of stoolsColor and size of stoolsChange of bowel habitsChange of bowel habitsRectal bleedingRectal bleedingBlack tarry stoolsBlack tarry stoolsHemorrhoidsHemorrhoidsConstipationConstipationDiarrheaDiarrhea


Gastrointestinal:Gastrointestinal:

Abdominal painAbdominal pain

Food intoleranceFood intolerance

JaundiceJaundice

Liver or gallbladder troubleLiver or gallbladder trouble

hepatitishepatitis


Urinary:Urinary: Frequency of urinationFrequency of urination PolyuriaPolyuria NocturiaNocturia Burning or pain on urinationBurning or pain on urination HematuriaHematuria UrgencyUrgency Reduces caliber or force if the urinary streamReduces caliber or force if the urinary stream IncontineceIncontinece stonesstones


GenitalGenital::Female:Female: Age at menarcheAge at menarche RegularityRegularity FrequencyFrequency Duration of periodsDuration of periods Amount of bleedingAmount of bleeding Last periodLast period


Genital:Genital:Femal:Femal: DysmenorrheaDysmenorrhea Premenstrual tensionPremenstrual tension Age at menopausaAge at menopausa ItchingItching Sexually transmitted diseasesSexually transmitted diseases Number of pregnanyciesNumber of pregnanycies Number and type of deliveryNumber and type of delivery Number of abortionNumber of abortion


Genital:Genital:

Male:Male: HerniasHernias Testicular painTesticular pain Sexually transmitted diseasesSexually transmitted diseases


Periferla vascular:Periferla vascular: Intermitten claudicationIntermitten claudication Leg crampsLeg cramps Varicose veinsVaricose veins Past clots in the veins Past clots in the veins


Musculoskeletal:Musculoskeletal: Muscle pain, weaknessMuscle pain, weakness Joint painJoint pain StiffnessStiffness ArthritisArthritis GoutGout BackacheBackache


Neurologic:Neurologic:

1.1. SeizeresSeizeres

2.2. WeaknessWeakness

3.3. ParalysisParalysis

4.4. Numness or loss of sensationNumness or loss of sensation

5.5. TremorTremor


HematologicHematologic AnemiaAnemia Easy bruising or bleedingEasy bruising or bleeding Past transfusionPast transfusion


EndocrineEndocrine Thyroid troubleThyroid trouble Heat or cold intoleranceHeat or cold intolerance Excessive sweatingExcessive sweating DiabetesDiabetes Excessive thirst or hungerExcessive thirst or hunger polyuriapolyuria

Establishing RapportEstablishing Rapport

The initial contact with the patient sets the foundation The initial contact with the patient sets the foundation for the relationshipfor the relationship

Good interviewing technique allows patients to Good interviewing technique allows patients to recount their own stories spontaneouslyrecount their own stories spontaneously

You should listen actively and watch for clues to You should listen actively and watch for clues to important symptoms, emotions events, and important symptoms, emotions events, and relationshipsrelationships

You can than guide the patient into telling you more You can than guide the patient into telling you more about the areas that seem most significant.about the areas that seem most significant.

This is done by using This is done by using direct questioningdirect questioning Questionts should proceed from the general to the Questionts should proceed from the general to the

specificspecific

Sometimes patients seem quite unable to describe Sometimes patients seem quite unable to describe their symptoms without helptheir symptoms without help

Offer multiple-choice answersOffer multiple-choice answers” Is your pain ” Is your pain achingaching, , sharp, pressing, burning, shooting, or whatsharp, pressing, burning, shooting, or what??

Use lanquage that is undestandable and appropiate to Use lanquage that is undestandable and appropiate to the patientthe patient

Establishing the sequence and time course of the Establishing the sequence and time course of the patient’s symptoms is importantpatient’s symptoms is important

You can encourage a chronologic account by such You can encourage a chronologic account by such questions as” questions as” What thanWhat than?” or „?” or „What happened nextWhat happened next?”?”

Generating and Testing Generating and Testing Diagnostic HypothesesDiagnostic Hypotheses

As you learn about the patient’s story As you learn about the patient’s story and the symptoms, you should be and the symptoms, you should be generating hypotheses about what body generating hypotheses about what body systems might be involved by a systems might be involved by a pathologic processpathologic process

For example, leg pain, suggests a For example, leg pain, suggests a problem in the peripheral vascular, problem in the peripheral vascular, musculoskeletal, or nervous systemmusculoskeletal, or nervous system

1. Its location.Where is it? Does it radiate?1. Its location.Where is it? Does it radiate? 2. Its quality. What is it like?2. Its quality. What is it like? 3. Its quantity or severity. How bad is it?3. Its quantity or severity. How bad is it? 4. Its timing. When did or does it start? 4. Its timing. When did or does it start?

How long does it last? How often does it How long does it last? How often does it come?come?

5. The setting in which it occurs, including 5. The setting in which it occurs, including enviromental factors, personal activities, enviromental factors, personal activities, emotional reactions.emotional reactions.

6. Factors that make it better or worse.6. Factors that make it better or worse.

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Principles of history taking. Reviewing the Chart: The medical chart give you valuable information about past diagnosis and treatment You should look