HISTORY TAKING

“Always listen to the patient

thepby might be telling you the
Diagnosis”

Sir William Osler (1849-1919)

DR. RUQAYA AL-KATHIRY

HEAD OF THE INTERNAL MEDICINE DEPARTMENT
DAR AL-SALAM INTERNATIONAL UNIVERSITY FOR SCIENCE & TECHNOLOGY
 Treatment
Hx Taking

Provisional Final
Dx Dx

PE
 The art of history taking is the
most fundamental skill in medicine

It can be acquired by:

1. Good teaching before and after qualifying
2. Careful observation of others how they take histories
3. A willingness to invite or accept comments & criticism
4. Constant self-scrutiny

Thus the Dr. should build up a strong “patient-doctor relationship”

which is established in the 1st meeting during Hx talking.
The doctor–patient relationship should be
‘based on openness, trust and good
communication’ and allow the Dr. to
‘work in partnership with the patient to
address their individual needs’.
 Communication is the key to a
successful interview.
The interviewer must be able to ask
questions of the patient freely. These
questions must always be understood
easily and adjusted to the medical
sophistication of the patient. If necessary,
slang words describing certain conditions
may be used to facilitate communication
and avoid misunderstanding.
Doctors are expected to:
 be polite, considerate & honest
 treat pts with dignity
 treat each pt as an individual
 respect pts’ privacy & right to confidentiality
 support pts in caring for themselves to
improve & maintain their health
 encourage pts who have knowledge about
their condition to use this when they are
making decisions about their care.
 Although these principles of care should
be reflected in all patient-doctor
relationships, different forms of
relationship will evolve depending on the
level of trust and willingness expressed by
the patient and the level of openness and
the communication structure employed by
the clinician.
TYPES OF DOCTOR–PATIENT RELATIONSHIP
4 forms of relationship are described with differing levels of pt
or Dr control:

I-Paternalistic
 Typical Dr-centred style
 Uses closed Qs to elicit yes/no answers
 Concentrates on the Dr’s decisions around
Dx & Rx rather than the pt’s view or
experience of their illness
TYPES OF DOCTOR–PATIENT RELATIONSHIP
4 forms of relationship are described with differing levels of pt
or Dr control:

II-Consumeristic
 Pt takes the active role
 Dr accedes to the pt’s request as a 2nd
opinion
TYPES OF DOCTOR–PATIENT RELATIONSHIP
4 forms of relationship are described with differing levels of pt
or Dr control:

III-Default
 Pt-centred approach
 Dr offers the pt involvement in decision-
making, but the pt prefers to choose a
passive role ‘whatever you think best, doctor’
TYPES OF DOCTOR–PATIENT RELATIONSHIP
4 forms of relationship are described with differing levels of pt
or Dr control:

IV-Mutualistic
 Both pt & Dr jointly exchange information &
agree a plan
 using an open questioning style.
SEATING ARRANGEMENTS

Distracted

Barrier
SEATING ARRANGEMENTS
 RULE OF FIVE VOWELS IN AN INTERVIEW

• Audition: listen carefully to the patient’s story.

• Evaluation: sorting out relevant from
irrelevant data and the importance of the data.
• Inquiry: probe into significant areas in which
more clarification is required.
• Observation: importance of nonverbal
communication, regardless of what is said.
• Understanding: the patient’s concerns and
apprehensions enables the interviewer to play
a more empathetic role.
 DEFINING BOUNDARIES

The Dr-pt relationship is an unusual

invasion of personal privacy permissible
only by the definition of unspoken
boundaries between the 2 parties.
It is important to:
 DEFINING BOUNDARIES

• Strike a balance b/w showing compassion

for a pt & allowing personal friendship where
you feel a pt has developed an unhelpful
personal attachment to you, it can be worth
discussing this with colleagues & arranging
a transfer of pt care; meantime you have a
duty to maintain pt care
 DEFINING BOUNDARIES

• Not enter into romantic or personal

relationships with existing, or even prior, pts

• Take special care where consultations are

not witnessed, e.g. on home visits, not to be
too familiar in approach & not to undertake
personal examinations at home if these can
wait
 DEFINING BOUNDARIES

• Be cautious about accepting gifts of

significant value from pts

• Avoid seeing pts within the context of your

home or personal social environment

The doctor patient relationship can be a

challenging responsibility, but is also a
tremendously rewarding privilege.
 THE STANDARD HISTORY FRAMEWORK

There is a tried and tested standard sequence which

all practitioners use and stick to it:
• Personal history or data
• Chief or presenting complaint
• History of present illness or complaint
• Review of other system or systematic enquiry
• Past history
• Drug history
• Family history
• Socioeconomic history
• Gynaecologic and obstetric history
• Immunization history
1-PERSONAL HISTORY (Hx):
• Name
• Age
• Gender
• Address (place of birth and residence)
• Ethnic background
• Marital status
• Educational Level
• Occupation (or previous occupations if retired).
• Religion
• Handedness
• Blood Group
1-PERSONAL HISTORY (Hx):
• Source of information
• Day & Date of admission
• Time of admission
• Admission through ER / OPD / Referral paper of
hospital
• Special habits of medical importance N.B: These may
be included here e.g.:
1-PERSONAL HISTORY (Hx):
 Smoking:
BE AWARE OF CULTURAL ISSUES
• Ask about previous smoking as many will call
themselves non-smokers if they gave up yesterday or
even on their way to the hospital or clinic.
• Active / Passive
• Quantity
• Type
1-PERSONAL HISTORY (Hx):
 Smoking:
Smoking index

• Never smokers (0 pack years)

• Light smokers (0.1-20.0 pack years)
• Moderate smokers (20.1-40.0 pack years)
• Heavy smokers (> 40 pack years)
Q. WHAT ARE THE TOBACCO RELATED DISEASES?
1-PERSONAL HISTORY (Hx):
 Alcohol:
BE AWARE OF CULTURAL ISSUES
• Duration: continuous or intermittent (2 alcohol-free
days/week)
• Type: beer or wine
• Amount: glasses/day.
• Calculate the average units/week (current
recommended weekly allowance is 21U for men & 14U
for women)
Q. WHAT ARE THE ALCOHOL RELATED DISEASES?
1-PERSONAL HISTORY (Hx):
 Qat chewing:
• Duration
• Type
• Amount

 Drug Abuse:
BE AWARE OF CULTURAL ISSUES
‘Illicit’ or ‘recreational’ drug use or medication
• Type of drug (eg. cocaine, propranolol)
• Route of administration
• Site
• Frequency of use
• Shared needles
2-CHIEF COMPLAINT (C/C):
“The problem which made the pt. seek medical advice.”
2-CHIEF COMPLAINT (C/C):
‘What’s the problem?’ or ‘What made you come today?’

• Record in pt.’s own words rather than medical terms.

• Time & duration of symp. (minutes, hours, days,

weeks, months) before the time of consultation

• Chronological order (from the 1st till the last symptom

regarding appearance).

• As short as possible 1 complaint (the most

important) if multiple maximum 3 should be listed.
3-HISTORY OF PRESENT ILLNESS (HOPI):
REMEMBER, THIS SHOULD FEEL LIKE A CONVERSATION,
NOT AN INTERROGATION!

• Ask the pt. to tell you the story of the illness from the
beginning up to date by ‘open’ Qs

• Do not interrupt (BE A GOOD LISTENER) show the

pt you are interested in what they have to say (adopt
an attentive posture, maintain good eye contact, gesture with
your hands or nod your head accordingly, and summarizing
salient points) unless the pt. is talkative & is not near
the point (TAKE CONTROL) or to encourage a
nervous one to talk freely.
3-HISTORY OF PRESENT ILLNESS (HOPI):
3-HISTORY OF PRESENT ILLNESS (HOPI):
3-HISTORY OF PRESENT ILLNESS (HOPI):

• Gently discourage a pt. who uses medical terms

without really knowing their meaning & ask them to
describe what they actually feel.
3-HISTORY OF PRESENT ILLNESS (HOPI):

• Begin talking to the pt. but clarification may be

sought from relatives or friends.

• Understand the pt.'s story clearly then analyze each

main symptom in turn.

• Avoid, as far as possible leading Qs which suggest

an answer, although direct Qs ‘closed’ questions
may be essential esp. as the interview proceeds.
3-HISTORY OF PRESENT ILLNESS (HOPI):
3-HISTORY OF PRESENT ILLNESS (HOPI):
3-HISTORY OF PRESENT ILLNESS (HOPI):

• Use medical terms with chronological development

of the condition with precise dates while taking quick
notes. Don’t document every word they say as
this breaks your interaction!

• Mention the positive & important negative symptoms

as they may indicate the specific involvement of a
system.

‘I’d just like to go through the story again,

clarifying some details to summarize’.
3-HISTORY OF PRESENT ILLNESS (HOPI):
SOCRATES

A mnemonic that summarises the Qs that should be

asked mainly about pain but could be used in other
symptoms with the exclusion of some.

• S = Site & Severity

• O = Onset
• C = Character & Course
• R = Radiation, Referred & Relieving factors
• A = Aggravating factors & Associated symptoms
• T = Timing
3-HISTORY OF PRESENT ILLNESS (HOPI):
SOCRAT

 Site:
• Where exactly?
• Localised or diffuse? Ask the pt to point
• Observe body language

 Severity:
• Subjective
• Does it interferes with NL activities or
sleep?
• Grading
3-HISTORY OF PRESENT ILLNESS (HOPI):
SOCRAT

 Onset:

• Sudden / Acute: vascular events as MI, stroke, SAH

• Gradual / Chronic: cannot be dated exactly as

weight loss or dysphagia may indicate malignancy
3-HISTORY OF PRESENT ILLNESS (HOPI):
SOCRAT

 Course:
• Constant (continuous)

• Intermittent (relapses or remissions)

• Progressive (deteriorating)

• Regressive (improving)
3-HISTORY OF PRESENT ILLNESS (HOPI):
SOCRAT

 Character:
• Clarify from the pt.
• It may be necessary to suggest some alternative
descriptions:
o Nociceptive (somatic or visceral): aching,
squeezing, throbbing, cramping, gnawing,
localised, heaviness, tearing, splitting
o Neuropathic: shooting, radiating, stabbing,
burning, electric shock-like
3-HISTORY OF PRESENT ILLNESS (HOPI):
SOCRAT

 Radiation:
• Does it spread elsewhere?
• Pattern of radiation is very suggestive of
certain ABNLities
3-HISTORY OF PRESENT ILLNESS (HOPI):
SOCRAT

 Referred:
3-HISTORY OF PRESENT ILLNESS (HOPI):
SOCRAT

 Relieving Factors:
• Anything that makes it better?
3-HISTORY OF PRESENT ILLNESS (HOPI):
SOCRAT

 Aggravating Factors:
• Anything that makes it worse?

 Associated Factors:
• Other symptoms of the involved system?
3-HISTORY OF PRESENT ILLNESS (HOPI):
SOCRAT

 Time:
• Morning or Night
• Duration
4-REVIEW OF OTHER SYSTEMS (ROS):
“This is a guide to not miss anything.”
Symptoms of the related system should be described in the
HOPI not in the ROS.
Q. ASSIGNMENT: DEFINE ALL THESE SYMPTOMS.

 GENERAL:
• WEIGHT CHANGES: LOSS / GAIN
• APETITE CHANGE: ANOREXIA / POLYPHAGIA
• WEAKNESS
• FATIGUE
• FEVER, CHILLS, RIGORS, SWEATING
• LUMPS
• EAR DISCHARGE
• MOUTH & THROAT PAIN
• NECK PAIN OR LUMP
4-REVIEW OF OTHER SYSTEMS (ROS):
 CARDIOVASCULAR SYSTEM:
• CHEST PAIN (SOCRATE)
• DYSPNOEA:
o EXERTIONAL
o AT REST, ORTHOPNEA; PAROXYSMAL NOCTURNAL
DYSPNOEA
• COUGH; SPUTUM; HAEMOPTYSIS
• PALPITATION
• OEDEMA: LOCALIZED / GENERALIZED
• SYNCOPE OR PRE-SYNCOPE
• INTERMITTENT CLAUDICATION
• CHANGE IN THE COLOUR
• CHANGE IN TEMPERATURE OF THE FEET
4-REVIEW OF OTHER SYSTEMS (ROS):
 RESPIRATORY SYSTEM:
• COUGH; SPUTUM; HAEMOPTYSIS
• DYSPNOEA
o EXERTIONAL
o AT REST; ORTHOPNEA; PAROXYSMAL NOCTURNAL
DYSPNOEA
• CHEST PAIN: PLEURISY (SOCRATE)
• WHEEZE
• STRIDOR
• SNORE OR FALL ASLEEP DURING THE DAY
UNEXPECTEDLY
• SYSTEMIC MANIFESTATIONS:
o FEVER
o SWEATING
o RIGORS
o CHILLS
4-REVIEW OF OTHER SYSTEMS (ROS):
 UPPER GASTROINTESTINAL SYSTEM:
• CHANGE OF APETITE: ANOREXIA / POLYPHAGIA
• WEIGHT CHANGES: LOSS / GAIN
• ORAL ULCERS
• HALITOSIS
• SALIVATION CHANGES: XEROSTOMIA / PTYALISM
• BELCHING
• WATER BRUSH
• HEARTBURN
• DYSPHAGIA
• ODYNOPHAGIA
• HICCUPS
• DYSPEPSIA
• NAUSEA
• VOMITING
• ABDOMINAL PAIN: (SOCRATE)
4-REVIEW OF OTHER SYSTEMS (ROS):
 LOWER GASTROINTESTINAL SYSTEM:
• ABDOMINAL PAIN: (SOCRATE)
• FLATULENCE
• BLOATING
• ABDOMINAL DISTENSION
• CHANGE IN BOWEL HABIT: CONSTIPATION / DIARRHOEA
• INCONTINENCE
• HAEMATEMESIS
• MELAENA
• HAEMATOCHEZIA

 HEPATOBILIARY SYSTEM:
• ABDOMINAL PAIN: (SOCRATE)
• JAUNDICE
• PRURITIS
4-REVIEW OF OTHER SYSTEMS (ROS):
 GENITOURINARY SYSTEM:
URINARY SYMPTOMS:
• DYSURIA
• FREQUENCY
• INCONTINENCE
• DRIBBLING
• URGENCY
• HESITANCY
• NOCTURIA
• HAEMATURIA
• FROTHY URINE
• CHANGE IN THE AMOUNT OF URINE:
o POLYURIA
o OLIGURIA
o ANURIA
• LOIN PAIN: (SOCRATE)
4-REVIEW OF OTHER SYSTEMS (ROS):
 GENITOURINARY SYSTEM:
GENITAL SYMPTOMS:
‘I need to ask you some personal questions because they
may be relevant to your current state of health.’
IT IS NOT YOUR ROLE TO MAKE JUDGEMENTS ABOUT A
PERSON’S LIFE.
• DISCHARGE: URETHRAL / VAGINAL
• ITCHING
• PAIN / DISCOMFORT GROIN PAIN: (SOCRATE)
• ULCER
• RASH
• SEXUAL HISTORY: should be detailed if suspected STI
• IMPOTENCE
• INFERTILITY
• MASSES
4-REVIEW OF OTHER SYSTEMS (ROS):
 NEUROLOGICAL SYSTEM:
• HEADACHE: (SOCRATE)
• FITS / SEIZURES / CONVULSIONS
• FAINT / SYNCOPE
• CONCIOUSNESS DISTURBANCE
• PERSONALITY CHANGES
• DISTURBANCE OF
• VISION
• SMELL
• TASTE
• HEARING
• BALANCE
• SPEECH
• SLEEP
4-REVIEW OF OTHER SYSTEMS (ROS):
 NEUROLOGICAL SYSTEM:
• PHOTOPHOBIA
• EYE PAIN
• DIPLOPIA
• FACIAL PAIN OR NUMBNESS
• VERTIGO
• LOSS OF SPHINCTER CONTROL
• MUSCLE WEAKNESS: PARAESIS / PARALYSIS
• ABNORMAL
• MOVEMENTS
• SENSATION
• AUTONOMIC DYSFUNCTION
4-REVIEW OF OTHER SYSTEMS (ROS):
 ENDOCRINE SYSTEM:
• FATIGUE
• POLYURIA,POLYDIPSIA & POLYPHAGIA
• NECK SWELLING
• HEAT / COLD INTOLERANCE
• APETITE CHANGES
• WEIGHT CHANGES
• HYPERHYDROSIS / ANHYDROSIS
• PALPITATION, TREMORS & PERSPIRATION
• SKIN & MUCOSAL PIGMENTATION:
o HYPOPIGMENTATION / HERPIGMENTATION
• CHANGE IN THE SIZE OF HAND & FEET
• CHANGES IN SEXUAL FUNCTION:
o IMPOTENCE, IMPAIRED FERTILITY
• HIRSUTISM / ALOPECIA
• MYOPATHY
4-REVIEW OF OTHER SYSTEMS (ROS):
 MUSCULOSKELETAL SYSTEM:
• PAIN: JOINT, MUSCLE, BONE (SOCRATE)
• SWELLING
• REDNESS
• HOTNESS
• STIFFNESS: TIME & DURATION?
• LIMITATION OF MOVEMENT
• WEAKNESS
• DEFORMITY
• RASH
• EXTRA-ARTICULAR INVOLVEMENT
4-REVIEW OF OTHER SYSTEMS (ROS):
 HAEMATOLOGICAL SYSTEM:
• LASSITUDE, DYSPNEA & PALPITATION
• FEVER (INFECTION)
• BLOOD LOSS FROM ANY ORIFICE, EASY BRUISING
• SWELLING & GLANDULAR ENLARGEMENT:
o LYMPH NODES
o SPLEEN
o BONE
o MENINGES
o ORBITS
4-REVIEW OF OTHER SYSTEMS (ROS):
 DERMATOLOGICAL SYSTEM:
• SKIN:
o RASH
o DISTRIBUTION
o ITCHING
o DRYNESS
• NAILS
• HAIR
5-PAST HX:
 MEDICAL HX:
• Chronic diseases:
o D.M, heart disease (IHD, HF, RF), HT, Hypercholesterolaemia
o COPD, T.B, B.A
o PUD, CLD (Liver cirrhosis), jaundice
o Kidney stones
o Stroke, TIA, Epilepsy
o Hypothyroidism
o SLE, RA
Q. SINCE, WHERE, HOW & BY WHOM IS IT DX?
Q. COMPLICATIONS?
Q.RX DETAILS?
Q. ANY ACTIVE PROBLEMS?
Q. FOLLOW-UP ARRANGEMENTS?
5-PAST HX:
 MEDICAL HX:
• Previous hospitalizations: WHEN?
o Similar or different condition

• Past screening tests: WHEN?

o Papanicolaou (Pap) smear
o Mammography
o CXR
o FOB testing
o Colonoscopy
5-PAST HX:
 SURGICAL HX:
• Surgical operations:
o Type (major/minor)
o Date, hospital & surgeon’s name
o Complications (Anaesthetic or surgical)
• History of trauma:
o Type of accidents (RTA or falls)
o Date
• Blood transfusions:
o Amount (250ml / 500ml=1/2 or 1 pint of blood)
o Date
o Indications
o Reactions
6-FAMILY HX:
 MEMBERS:
• PARENTS Consanguinity
• WIFE/HUSBAND Consanguinity
• SIBLINGS & CHILDREN:
o Number
o Gender
o Alive = Age & health status
o Dead = Age & cause

 SIMILAR CONDITION IN THE FAMILY

6-FAMILY HX:
 HISTORY OF ANY HEREDITARY OR
ENVIRONMENTAL FACTORS:
• D.M
• HT, IHD, Stroke
• B.A, T.B
• Thyroid Disease
• Blood Diseases
• Autoimmune Diseases
• CA (Breast, colon, prostate)
• Schizophrenia
6-FAMILY HX:

pt that you are talking to

6-FAMILY HX:

E.g. pt is an only child and has no children, his parents are

alive but all his grandparents have died of different causes
7-DRUG HX:
Current or previous medications
 PRESCRIBED DRUGS:
• Identity (name: generic or trade) of the drug
• Route of administration
o PO: per orum i.e. by mouth (tablet, capsule, syrup)
o Injections: I.V / I.M / S.C
o Inhalers, Sprays
o Skin crème, Patches
o Eye drops
o Suppositories
• Dose (mcg, mg, g)
• Duration
7-DRUG HX:
Current or previous medications
 PRESCRIBED DRUGS:
• Frequency of administration
o o.d = once daily
o b.d (bis die) = twice daily
o t.d.s (ter die sumendus) / t.i.d (ter in die) = thrice daily
o q.d.s (quarter die sumendus) / q.i.d (quarter in die) =
four times/d
• Compliance/adherence
7-DRUG HX:
 NON-PRESCRIBED DRUGS:
• Over the counter (OTC): analgesics; OCPs; psychotropic
drugs as sleeping pills; vitamin or mineral supplements,
indigestion medicine, laxatives
• Alternative Therapies: Herbal remedies, acupuncture

 DRUG ALLERGIES:
FAILURE TO ASK THE QUESTION OR TO RECORD THE ANSWER
PROPERLY MAY BE LETHAL.
• What type of reaction? Specific symp. of an allergy (e.g.,
rashes, nausea, itching, anaphylaxis) should be clearly indicated.
Decide if the pt is describing a true allergy, an intolerance or
simply an unpleasant S.E.
• Other allergies? food, seasonal, insects or latex
 DRUG INTERACTIONS
8-SOCIOECONOMIC HX:
“This is the chance to document the details of the
pt’s personal life which are relevant to the Dx”
 Diet:
• Regular
• Type (e.g. Vegetarian)
 Level of Exercise:
• Regular
• Lift / Stairs
 Occupation:
• Type: sitting at a desk, carrying heavy loads, travelling
• Hours
• Potential hazards (e.g. Chemicals)
8-SOCIOECONOMIC HX:
 Animal Contact:
o DOES THE PATIENT OWN ANY PETS?
• Animal breeding: type & duration
 Traveling Abroad:
• WHEN?
• WHERE? (overseas)
• Drug prophylaxis given to protect against diseases
• Vaccination given to protect against diseases
Q. WHAT ARE THE TRAVEL RELATED DISEASES?
 Financial Status:
• Income: Low / Moderate / High
o WHO SUPPORTS THE PATIENT?
 Recent stresses or worries:
8-SOCIOECONOMIC HX:
 Housing:
• Type of accommodation: (house, flat & on what floor)
• Owned / rented
• Rural / urban
• Occupants
• Rooms
• Bathrooms
• Electricity
• Ventilation
• Water supply
• Heating system
• Sewage system
9-IMMUNISATION HX:
• If small child or elderly patient
• Should be taken from the care giver
• Remote or recent:
o Combined toxoid (Tetanus & diphtheria)
o Influenza vaccine
o pneumococcal polysaccharide vaccine
o Hepatitis A vaccine
o Hepatitis B vaccine
o Haemophilus influenzae type B (Hib) vaccine
o Measles, mumps, and rubella (MMR)
10-GYNAECOLOGICAL AND OBSTETRIC HX (GOB):
 MENSTRUAL HX:
• Last menstrual period (L.M.P)
• Menarche
• Peri- or Postmenopause
• Days / Month
• Amount of blood loss; presence of clots
• Dysmenorrhea; if interferes with daily activities
• Premenstrual Tension
• OCPs
10-GYNAECOLOGICAL AND OBSTETRIC HX (GOB):
 OBSTETRIC HX:
G=P+A
• No. of pregnancies:
o Full-term / Preterm
o Alive / Dead
o Complications
• No. of deliveries:
o NVD / C/S
• No. of miscarriages (Abortions)
o Spontaneous / Induced
• Contraception methods
“Medicine is learned at
the bedside and not in
the classroom”
Sir William Osler (1849-1919)
THANK YOU FOR YOUR ATTENDANCE