Introduction to History Taking

Introduction to History Taking

Introduction:
• Medical history is fundamental in internal medicine.
• 90% of answers to patient problems can be found in their history.
• Investigations are used in the remaining 10% of cases.
Identification:
• Patient's name, age, sex, home, and referral status.
• Example: Luke Smart, 32-year-old male, self-referral to Bugando Medical Centre.
Chief Complaint (CC):
• Main reason for hospital visit.
• Ask, "Why did you come to the hospital?"
• May include up to two or three main complaints.
• Include duration of the complaint.
• Example: Disturbance in breathing for two weeks.
History of Present Illness (HPI):
• Story of symptom development.
• Use patient's own words, avoid medical terminology.
• Begin with earliest symptoms related to CC and proceed chronologically.
• Example: Chest pain when walking up a hill, resolved with rest, recurred with
activity, shortness of breath, swelling in legs.
Review of Other Systems (ROS):
• Review systems not involved in CC.
• Usually done head to toe (neurological, cardiovascular, pulmonary, etc.).
• Mention important negatives and positives related to CC.
• Example: If CC is abdominal pain, mention gastroenterology in HPI, and
specifically mention cardiovascular, renal, and genitourinary systems in ROS if
relevant.
Past Medical/Surgical History (PMSHx):
• Includes past admissions, chronic medical problems, medications, allergies,
immunizations, surgeries, blood transfusions, gynecological history for women.

Lordin Alumasa Wanjala, Department of Clinical Medicine, JKUAT

 Introduction to History Taking

• Include parts of PMHx related to CC in HPI.

• Example: If CC is chest pain, and the patient was admitted for it two weeks ago,
include it in HPI.
• Ask about chronic medical problems and medication use.
• Include details like CD4 count and ART for patients with HIV.
• Allergy Section, Ask about the type of reaction to allergies.
• If unsure about the specific medication, inquire about why they were taking it or
if it was a pill or intravenous medication.
• For women, include the last menstrual period.
Family/Social History (FSHx):
• Marital status, number of children, home location (region/village), home type,
occupation, education level, alcohol use, tobacco use, illicit drug use, and sexual
history.
• Tobacco history: Number of cigarettes per day and years smoked (reported in
pack years).
• Alcohol history: Type, amount per sitting, frequency, and total years of drinking
at that level.
• Sexual history: Number of current/past partners, history of sexually transmitted
infections, age at first intercourse, use of protection.
Family History:
• Inheritable diseases (e.g., diabetes mellitus, sickle cell disease, heart disease).
• Diseases related to the chief complaint.
Summary #1:
• A single sentence summarizing key history elements.
• Include identifying information, CC, brief HPI description, essential ROS,
PMSHx, and FSHx details.
• Example: "This is a 30yo new diagnosis of IDS, who presented with a 2-week
history of difficulty breathing associated with chest pain, fever, weight loss, night
sweats, and a TB contact."
Physical Exam:
• Start with the general exam.
• Report vital signs at the end of the general exam.

Lordin Alumasa Wanjala, Department of Clinical Medicine, JKUAT

 Introduction to History Taking

• Example: "Ill-appearing middle-aged male, extremely wasted, lying in bed. Vital

signs: temp 37.3°C, BP 105/70, pulse rate 105, O2 sat 92%."
• Report the most affected organ systems first.
• Complete physical exam for all organ systems but provide a detailed exam only
for those related to CC and abnormal findings in other systems
Organ System Examination Order (I.P.P.A.):
• Inspection
• Palpation
• Percussion
• Auscultation
• For the central nervous system, follow a different order.
Cardiovascular Exam:
• Start with the inverted J (radial pulse, blood pressure, JVP).
• Then proceed to I.P.P.A. for the precordium and rest of the cardiovascular exam.
• Report vital signs twice: once during the general exam and again with the
relevant organ system exam.
Summary #2:
• First sentence repeats Summary #1.
• Second sentence summarizes physical exam findings concisely, avoiding
repetition of specific details.
• For example, "Respiratory exam findings consistent with pleural effusion."
Impression:
• Consider the chief complaint and all abnormal history and physical findings.
• Include every diagnosis you believe the patient HAS.
• Provide reasoning behind each impression.
• Offer 3-5 differential diagnoses for each impression.
Plan:
• Organize by stating investigations and treatments for each impression.
• Example: "For IDS, order CD4 count, baseline ART labs (RFT, FBP, LFT). For
TB, collect sputum for AFB, check FBP, and request a chest x-ray."

Lordin Alumasa Wanjala, Department of Clinical Medicine, JKUAT

 Introduction to History Taking

• Create a consistent plan for each diagnosis to streamline future assessments.

Lordin Alumasa Wanjala, Department of Clinical Medicine, JKUAT