FOUNDATIONS OF CLINICAL

PROFICIENCY
 Parts of Medical History
• General Data
• Chief complaint
• History of Present Illness
• Past medical History
• Family History
• Social and Environmental History
• ROS
 Subjective data
vs
Objective data
SUBJECTIVE DATA OBJECTIVE DATA

What you detect during the examination,

What the patient tells you laboratory information and test data

The symptoms and history, from chief

complaint through Review of Systems All physical examination findings, or signs

Example: Mrs. G. is an older, overweight white

female, who is pleasant and cooperative.
Example: Mrs. G. is a 54-year-old hairdresser Height 5′4′′,
who reports pressure over her left chest “like weight 150 lbs,
an elephant sitting there,” which goes into her BMI 26,
left neck and arm. BP 160/80,
HR 96 and regular
respiratory rate 24,
temperature 97.5 F
 Procedure Steps and Parts
1. Introduce yourself, identify your patient and gain consent
to speak with them. Should you wish to take notes as you
proceed, ask the patients permission to do so.

2. General Data:
– Identifying data: Name, age, sex, civil, status,
occupation, nationality, religion, birthdate, birthplace,
present address, number of times admitted, hospital
being admitted to, date of admission.
– % reliability and Informant
Procedure Steps and PartsSteps
3. Presenting Complaint (PC)
• This is main reason for seeking medical attention; what
the patient tells you is wrong, for example: chest pain.

4. History of Presenting Complaint (HPC)

• A detailed and chronologic account of the patient’s
current problems for which he is seeking medical
attention
• Gain as much information you can about the specific
complaint.
POINTS TO REMEMBER IN ELICITING THE HPI:
1. Start the patient’s narrative by saying:“Tell me about your problem from the very
beginning up to the time you were brought to the hospital or consulted the clinic.” Elicit
further information by asking “anything else?”
2. The questions should be phrased properly so that the patient provides the information
rather than simply answering yes or no (OPEN QUESTION)
3. Allow the patient to recount his own story spontaneously without unnecessary
interruption.
4. Listen actively and carefully and watch for clues to important symptoms, emotions,
events, and then guide the patients into telling you more about these areas. (Many
students overlook the leads patient offer because of their concern over what questions
to ask next.)
5. Encourage the patient to relate a complete and factual account of illness, not affected or
biased by what you think the circumstance should be or by making premature
conclusion as to nature of illness
****The SOCRATES acronym can be used for any type of pain history: Site, Onset, Character,
Radiation, Associated factors, Time, Exacerbating/relieving factors, Severity (pain history
 Procedure Steps and Parts
5. Past Medical History (PMH)
– Gather information about a patients other medical problems (if any).
– List of childhood illnesses
– List of adult illnesses with dates of events in the least 4 categories: Medical; surgical; OB-GYNE and
psychiatric
• Medical: past illnesses or hospitalizations not related to the HPI (Date, name of hospital, described symptoms
or give diagnosis and results of treatment)
• Surgical: operations (full details including type, date, results and complications of surgery)
• Gynecologic: diseases affecting the reproductive organs
• Psychiatric: history of violence, suicidal attempts, drug overdose, substance abuse
• Accidents/injuries: date, time, sequelae
• Blood transfusion – date received, indications and complications
• Allergies: type
– Includes health maintenance practices such as immunizations
– Drug History (DH): Find out what medications the patient is taking, including dosage and how
often they are taking them, for example: once-a-day, twice-a-day, etc.
– Immunizations received: date and type of vaccine received. DO NOT USE THE TERM. “Complete
immunization or vaccination”
 Procedure Steps and Parts
6. Family History
– Gather some information about the patients
family history, e.g diabetes or cardiac history. Find
out if there are any genetic conditions within the
family, for example: polycystic kidney disease.
– Outlines or diagrams age and health or age and
cause of death of siblings, parents and
grandparents
– Any member of the family with similar symptoms.
 Procedure Steps and Parts
7. Social and Environmental History
– This is the opportunity to find out a bit more about the patient’s
background.
– Educational attainment
– Occupational History: nature of work, no. of hrs. exposure to hazards,
safety measure used
– Marital Status: health status of spouse and children, relationship with
spouse and children, exposure to STD, number and gender of sexual
partners
– Habits: sleep pattern, diet, coffee, alcohol intake, smoking, use of drugs
(prescribe, prohibited, self-medication, supplements) hobbies and
exercise,
– Living conditions, source of water, waste disposal, etc…
 Procedure Steps and Parts
8. Menstrual and Gynecologic History
– Age at menarche
– Interval, duration, and amount of flow
– Premenstrual symptoms
– LMP and PMP
– Gravidity and Parity: (G) no. of pregnancies,(P) deliveries of live babies
T- term, 38 week and above
P- premature, 21 to 37 weeks
A- abortion, 20 weeks and less; birth weight less than 500
grams
L- live births
– Manner of delivery (spontaneous vaginal delivery, caesarian section, forceps
extraction), place of delivery and postpartum complications.
 Procedure Steps and Parts
9. Review of System
A. Gather a short amount of information regarding the other systems in
the body that are not covered in your HPC.
B. A comprehensive survey of all complaints referable to each body
system
C. A search for symptoms that may have escaped the taking of the
present illness
– Question technique: begin by asking an open-ended question, followed by the
appropriate list of symptoms e.g. “How is your health in general?” “How are
your eyes?”, Any problem with your skin?”
– To record: Write (+) for presence of symptoms asked and (-) for its absence
D. Symptoms related to the patient’s current problem discovered
during your ROS inquiry should be recorded in your HPI
 Procedure Steps and Parts
10. Summary of History
– Complete your history by reviewing what the patient has told you. Repeat back
the important points so that the patient can correct you if there are any
misunderstandings or errors.
– You should also address what the patient thinks is wrong with them and what
they are expecting/hoping for from the consultation. A useful acronym for this
is ICE [I]deas, [C]oncerns and [E]xpectations. 
11. Patient Questions / Feedback
– During or after taking their history, the patient may have questions that they want
to ask you. It is very important that you don’t give them any false information.
12. When you are happy that you have all of the information you require,
and the patient has asked any questions that they may have, you must
thank them for their time and say that one of the doctors looking after
them will be coming to see them soon.
 Activity Suggestion
1. The preceptor act as patient and asking the student to do history
taking
2. submit written history after 24-48hours and grade the written
output(50 points)
– GD:5 pts
– CC:1point
– HPI-10points
– PMH-10
– Fhx-10
– Soc and Envt-10
– ROS:4points
3.Group Presentation(50points): grading sheet (attach to messenger
group)