History taking

Dr. Sonu Bhattarai

MDGP
Importance of history taking
History is the action or practice of recording a person’s medical history.Used to understand the patient’s
experience of illness.It is subjective description of patient’s symptoms for diagnosis and treatment.

To build a rapport with the patient

To create a story of the patients symptoms

To come to a potential diagnosis

To order relevant investigations

To give the right treatment

To be able to counsel the patient with good communication skills

Headings for history taking
Patient particulars

Chief complaints

History of present illness

Negative history/ systemic review

Past history

Personal history

Family history
Headings for history taking
Socioeconomic history

Drug and allergy history

Travel history

Occupational history

Obstetric and menstrual history

History taking(Patient particulars)
Name: Age: Gender:

Marital status: Occupation:

Religion:

Address:

Date of admission: Date of Examination:

Source of history( Patient/ relative) Informant: relation to patient:

Reliability of information: Accuracy of information:

History taking (Chief complaints)
History of chief complaint and duration of each in chronological order: 1….. 2…. 3….

State the major problem of patients in his/ her own words followed by duration of each

Medical terminology should be avoided

Major problem or symptoms which makes the patient come for check up

These symptoms are arranged in chronological order

Eg. Fever for 2 days

Chest pain for 2 hours

Which of the following is correct regarding chief complaint during history taking?

Chief complaint should comprise all the symptoms

No need to mention duration of symptoms

Chief complaint should comprise symptoms that made patient to visit hospital
Which of the following is correct regarding chief complaint during history taking?

Chief complaint should comprise all the symptoms

No need to mention duration of symptoms

Chief complaint should comprise symptoms that made patient to visit

hospital
Which of the following is incorrect regarding history of present illness during
history taking?

Should be written in chronological order

Should be framed as per patient description without technical words

Should be present in complete sentences

Should comprise all the complaints

Which of the following is incorrect regarding history of present illness during
history taking?

Should be written in chronological order

Should be framed as per patient description without technical words

Should be present in complete sentences

Should comprise all the complaints

Eliciting information according to system
Locomotor system

Joint pain or stiffness

Muscle pain or weakness

Eliciting information according to system
Cardiovascular system:
Palpitations

Chest pain

Ankle swelling

Pain in legs on exertion

Shortness of breath, Breathlessness on lying flat (orthopnoea)

Waking up with breathlessness (paroxysmal nocturnal dyspnoea)

Cough with or without sputum, Hemoptysis

Eliciting information according to system
Respiratory system

Shortness of breath

Exercise intolerance

Wheezing

Coughing

Sputum: colour, amount, presence of blood (hemoptysis)

Chest pain in relation to respiration and coughing

Eliciting information according to system
Gastrointestinal system

Abdominal pain

Dyspepsia

Dysphagia

Nausea and vomiting

Anorexia

Constipation
Eliciting information according to system
Gastrointestinal system

Diarrhoea

Abdominal distension

Rectal bleeding

Hematemesis

Malena
Eliciting information according to system
● Suggested standard questions:

Reproductive system

Male

Female
Male
Urinary symptoms

Penile discharge or dysuria

Scrotal swelling or pain

Penile skin lesions

Erectile dysfunction
Female
Abnormal vaginal bleeding

Lower abdominal pain

Dysmenorrhoea

Vaginal bleeding

Vaginal discharge

Abdominal distension and bloating

Urinary incontinence

Symptoms of prolapse
Breast lump

Breast pain

Skin changes

Nipple changes

Gynaecomastia
Symptoms in pregnancy
Physiological symptoms

Reduced fetal movements

Vaginal bleeding in pregnancy

Abdominal pain

Pruritus

Breathlessness
Genitourinary system
Pain passing urine: dysuria, increased frequency, urethral discharge

Frequency passing urine at night: nocturia

Blood in urine(haematuria)

Libido

incontinence(Stress and urge incontinence)

Sexual partners- unprotected intercourse

Eliciting additional information according to system
The endocrine system

Heat / cold intolerance

Prominence of eyes

Swelling of neck

Obesity

Tremors of fingers
Eliciting information according to system
The hepatobiliary system

Jaundice

Ascites
Eliciting information according to system
Nervous system

Headaches

Fits, faints, sleep patterns

Visual symptoms, double vision, loss of acuity

Tingling, numbness and muscle weakness

Hearing symptoms: deafness, tinnitus

Excessive thirst
History of present illness
Describe the onset, nature and course of each symptom in chief complaint

Communicate with open ended questions

Nonverbal communications should be noticed

Learn system wise questionnaires about common symptoms

Negative history: (no history of…. ) includes overview of other systems

System Wise questionnaires
Cardiovascular:

Do you ever have chest pain or tightness?

Do you ever wake up during the night feeling short of breath?

Have you ever noticed your heart racing or thumping?

System Wise questionnaires
Respiratory

Are you ever short of breath?

Have you ever had a cough? If so, do you cough anything up?

What colour is your phlegm?

Have you ever coughed up blood?

System Wise questionnaires
Gastrointestinal

Are you troubled by indigestion or heartburn?

Have you noticed any change in your bowel habit recently?

Have you ever seen any blood or slime in your stool?

System Wise questionnaires
Genitourinary

Do you ever have pain or difficulty passing urine?

Do you ever get up at night to pass urine? If so how often?

Have you noticed any dribbling at the end of passing urine?

Have your periods been quite regular?

System Wise questionnaires
Respiratory

Are you ever short of breath?

Have you ever had a cough? If so, do you cough anything up?

What colour is your phlegm?

Have you ever coughed up blood?

System Wise questionnaires
Musculoskeletal

Do you have any pain, stiffness or swelling in your joints?

Do you have any difficulty in walking or dressing?

Endocrine

Do you tend to feel the heat or cold more than you used to?

Have you been feeling thirstier or drinking more than usual?

System Wise questionnaires
Neurological

Have you ever had any fits, faints or blackouts?

Have you noticed any numbness, weakness or clumsiness in your arms or legs?
Mnemonics(OLD CARTS)
Onset

Location/ radiation

Duration

Character

Aggravating factors

Relieving factors

Timing

Severity
Fever
Onset: acute/ gradual

Duration

Severity: maximum temperature recorded

Type: continuous, remittent, intermittent

Diurnal variation

Relieving factors and aggravating factors

Associated factors: chills, rigors other symptoms

Medication taken for fever

Format for HOPI
My patient was apparently well 3 days back, when he /she started
having fever(acute/ insidious) in onset, (continuous/ intermittent/
remittent) type, with/ without (chills/ rigors), maximum temperature
(was …. documented/ not documented) (associated/ not
associated) with sweating. Relieved by taking (paracetamol.
spontaneously), associated with burning micturition.
Pain
Site and Onset

Duration

Severity and Type

Nature

Progression

Aggravating and relieving factors

Radiation, shifting
Format for HOPI
Abdominal pain (SOCRATES)

My patient was apparently well 6 hours back, when he started having

acute(onset), severe, (severity) burning pain(character) in the epigastrium(Site),
associated with nausea, relieved by taking some medication.(relieving factor)
There was no radiation or shifting of pain. (radiation)

Site, onset, character, radiation, alleviating factors, associated symptoms,

timing(duration, frequency), exacerbating factors, severity
Which pain is well localized?

a. Somatic pain
b. Visceral pain
c. Both
d. None
Which pain is well localized?

a. Somatic pain
b. Visceral pain
c. Both
d. None
Breathlessness
Onset

Duration

Aggravating factors

Relieving factors

Timing: variation: diurnal,

Severity
Palpitation
Onset

Duration

Character: intermittent, continuous

Aggravating factors: exercise, alcohol Associated symptoms: chest pain, lightheadedness, polyuria

Relieving factors: rest, valsalva

Timing

Severity
Presyncope and syncope
Onset

Loss of balance, lightheadedness

Duration; duration of unconsciousness

Character

Aggravating factors: medication, exercise, alcohol, associated features: palpitation, chest pain, breathlessness, aura, headache,
nausea, vomiting, confusion, hallucinations

Relieving factors

Timing:
Cough
Onset: Sudden or gradual

Frequency: continuous, intermittent; Duration:

Dry or productive:, If productive: amount, color, odour, consistency, blood

Character: Hacking, brassy, barking, paroxysmal

Aggravating factors: dust, pollen, cold air, posture, exercise Associated factors: fever, chest pain, breathlessness,
running nose, inhalation of foreign body

Relieving factors: rest;

Timing:Diurnal Variation

Severity
If productive sputum
Odour: foul smelling (infective in nature)

Duration

Colour: rusty, green, yellow, Bluish green

Consistency : sticky, non-sticky, purulent, mucoid

Amount

Blood : fresh, altered, rusty, pink, frothy

Hemoptysis
Onset; Duration

Coughed up alone or sputum stained by blood

Clots or frank bleeding

Altered blood or fresh; associated factors: cough, fever, expectoration

Refuting factors: epistaxis(nose bleeds), upper GI bleeding, vomiting; Reaction of blood: alkaline

Timing: preceding symptom: coughing

Severity: amount
Vomiting
Onset

Projectile/ Non projectile, Precipitating factor

Duration

Content: amount, color, odour, taste

Aggravating factors; Associated factors: nausea, retching , salivation, anorexia, abdominal pain, fever, diarrhoea,
any drug ingestion, headache, vertigo, weight loss.

Relieving factors

Timing/ Frequency: of vomiting

Blood: present/ absent

Blood in vomitus
Preceding symptoms: vomiting

Duration

Colour: Coffee ground

Altered or fresh blood, Amount; Associated symptoms: abdominal pain, vomiting,

Reaction of blood: acidic

Frequency

Severity: frequency and amount

Diarrhoea
Onset

Precipitating factors: particular food or drugs

Duration; last Defecation

Character of stool

Associated factors: pain, tenesmus

Relieving factors

Timing; Frequency

Severity
Character of stool
Odour

Colour

Consistency: watery, rice watery, slippery, jelly

Contents: blood, mucus, undigested food particles

Amount
Constipation
Onset

Duration

Character: Consistency of the stool

Associated factors: rectal bleeding, pain, weight loss, use of medications

Timing: Frequency: usual bowel habit and present habit

Severity
Dysphagia
Onset

Type of food: solid, liquid

Duration

Character: difficulty or sticky sensation after swallowing:

Associated factors: choking, nasal regurgitation, hoarseness of voice,

Timing of difficulty: at the beginning of swallowing or at the end

Severity: progression of severity

Jaundice
Onset

Duration

Character; Colour of urine, stool

Associated symptoms: pruritus, abdominal pain, fever, petechiae; blood transfusion; alcohol intake; drug intake

Recent travel; relevant family history

Swelling
Onset: How did the swelling start?

Location; other swellings

Duration: How long is the swelling present there? OR When was the swelling first noticed

Change in size of swelling? Exact size? Secondary changes? Softening, ulceration

Aggravating factors; Associated factors: pain, fever

Recurrence of swelling

Impairment of function
Ulcer
Onset

Preceding event: trauma/ spontaneously

Duration

Associated factors: Pain, discharge

Relieving factors: medications?

Typical patterns of symptoms related to disease causation

Disease causation: infection

Onset of symptoms: usually hours

Progression of symptoms: usually fairly rapid over hours or days

Associated symptoms/ pattern of symptoms: fever, rigors, localising symptoms,

e.g. pleuritic pain and cough
Typical patterns of symptoms related to disease causation

Disease causation: inflammation

Onset of symptoms: may appear acutely

Progression of symptoms: coming or going over weeks to months

Associated symptoms/ pattern of symptoms: nature may be multifocal, often with

local tenderness
Typical patterns of symptoms related to disease causation

Disease causation: metabolic

Onset of symptoms:very variable

Progression of symptoms:

Associated symptoms/ pattern of symptoms:

Typical patterns of symptoms related to disease causation

Disease causation: malignant

Onset of symptoms: gradual, insidious

Progression of symptoms: slowly progression over weeks to months

Associated symptoms/ pattern of symptoms: weight loss, fatigue

Typical patterns of symptoms related to disease causation

Disease causation: trauma

Onset of symptoms:abrupt

Progression of symptoms: little change from onset

Associated symptoms/ pattern of symptoms: diagnosis usually clear from history

Typical patterns of symptoms related to disease causation

Disease causation: vascular

Onset of symptoms:sudden

Progression of symptoms: rapid

Associated symptoms/ pattern of symptoms: rapid development of associated

physical signs
Typical patterns of symptoms related to disease causation

Disease causation: degenerative

Onset of symptoms:gradual

Progression of symptoms: months to years

Associated symptoms/ pattern of symptoms:gradual worsening with periods of

more acute deterioration
Past medical history
What illnesses have you seen a doctor about in the past?

Have you been in hospital before or attended a clinic?

Have you had any operations?

Do you take any medicines regularly?

He/she has no past history of asthma, tuberculosis, hypertension, diabetes,

jaundice, epilepsy

Diabetes in symptoms of peripheral vascular disease.

Whooping cough in bronchiectasis.

Birth history
History of birth in case of infants and children

Taken from mother

In a case of child, best history is taken from

a. Mother
b. Sister
c. Father
d. Brother
In a case of child, best history is taken from

a. Mother
b. Sister
c. Father
d. Brother
Family history
Are there any illnesses that run in your family?

Have any of your family had heart trouble?

Document illness in first degree relative: parents, sibling, children

Pedigree chart using symbols to be recorded

Family history is important in hemophilia

Personal history
Bowel

Bladder

Appetite

Sleep history

Alcohol. Smoking

Vegetarian / non vegetarian

Smoking
Tobacco use increases

Obstructive lung disease

Cardiac and vascular disease

Peptic ulceration

Intrauterine growth restriction

Erectile dysfunction

Cancers
Smoking
Age at which smoking started

Average number of cigarettes per day

Form of tobacco used ( cigarettes, cigars, pipe, chewed)

Convert to pack years

Passive smoking
Calculating pack years of smoking
A pack year is smoking 20 cigarettes a day(1 pack) for 1 year

Number of cigarettes smoked per day X Number of years smoking

20

15 X 40 = 30 pack years

20
1 pack year is
a. 20
b. 30
c. 40
d. 10

15 cigarettes per day for 15 years, gives a total of …… pack years

15 cigarettes per day for 15 years, gives a total of 11.25 pack years
Alcohol
Type of drink

Daily and weekly pattern (esp. Binge drinking or morning drinking)

Quantity

Usual place of drinking

Alone or accompanied

Units of alcohol consumed

Quantity
Alcohol consumed each week should be recorded in units

1 unit=10 ml of ethanol

1 unit= one small of wine

1 unit= half a pint of beer or lager

1 unit= 25ml of spirits

Hazardous drinking= >14 units per week for both men and women

Binge drinking; large amount of alcohol causing acute intoxication

Units of alcohol = multiply the volume of the drink in ml and % alcohol by volume

Divided by 1000

Alcohol by volume = number of millilitres(ml) of pure ethanol present in 100 ml of

solution

Spirits (whiskey, gin 40% abv)

Wine (5.5-16%)

Beer (4-6%)
Alcohol dependence
When alcohol use takes priority over other behaviour that previously had great value

A strong and overpowering desire to take alcohol

Inability to control starting or stopping drinking and the amount that is drunk

Drinking alcohol in the morning

Tolerance, where increased doses are needed to achieve the effects originally
produced by lower doses
Alcohol dependence
A withdrawal state when drinking is stopped or reduced, including tremor, sweating,
rapid heart rate, anxiety, insomnia, seizures, disorientation, hallucinations (delirium
tremens); that is relieved by more alcohol

Neglect of other pleasures and interests

Continuing to drink in spite of being aware of the harmful consequences

CAGE questionnaire for alcohol intake
Cut down: Have you ever felt you should cut down on your drinking?

Annoyed: Have people annoyed you by criticising your drinking?

Guilty: have you ever felt bad or guilty about your drinking?

Ever: do you ever have a drink first thing in the morning to steady you or to help a
hangover(‘an eye opener’)?

Positive answers to two or more questions suggest a problem drinking; confirm

this by asking about the maximum intake.
Drug history
What drugs are you taking? How often and how much?

How long have you been taking drugs?

Do you ever inject? If so, where do you get the needles and syringes?

Do you ever share needles, syringes or other drug- taking equipment?

Do you see your drug use as a problem?

Do you want to make changes in your life or change the way you use drugs?

Have you ever been checked for infections spread by drug use?
Drug history
Drug name, dosage, duration of treatment, previous adverse drug reactions

Concordance: patient and doctor have negotiated and reached an agreement on

management.

Adherence: patients who take their medication as prescribed

Drug allergies/ reactions

Allergy to foodstuffs, drugs, pollen

Non- prescribed drug use:over the counter remedies, herbal and homeopathic,
vitamin or mineral supplements
Social history
Social support in frail or disabled, attitude to needing help

Living circumstances

Type of housing, size, owned, rented

Details of occupation, housing, family/ school. Workplace relationships

Menstrual history (terms)
Menarche: Age at which period begin

Last menstrual period: Date of the first day of the last period

Lengths of period: Number of days the period lasts

Amount of bleeding: How heavy is bleeding, number of fully soaked pads in a

day passage of clots

Regularities of periods: Number of days of each period, pattern: regular,

irregular

Dysmenorrhoea: pain associated with menstruation, Does the pain precede or

occur during the period.
k=a b/c
K: Menses

A: age at menarche

B: Bleeding time(number of days of flow)

C: days of cycle

k= 12 4-5/25-29
Obstetric history
Pregnacies: Record parity, gravida, abortion

Parity:

Gravida:
S.No Year Pregnancy Date of Method of Puerperiu Baby wt. At birth, sex,
. and events delivery delivery m birth asphyxia, duration
month of breast feeding,
immunization,
contraception
Infertility
Infertility: Is the patient trying to become pregnant? If yes then for how long?
Contraception
Current/ Previous method of contraception

Temporary/ permanent contraception

Hormonal contraception

Intrauterine contraception
Sexual history
Are you currently in a relationship?

How long have you been with your partner?

Is it a sexual relationship?

Have you had any (other) sexual partner in the last 12 months?

How many males? How many females?

When did you last have sex with: your partner? Anyone else?

Do you use barrier contraception-sometimes, always or never?

Are you concerned about any sexual issues?

SAMPLE
S- signs/ symptoms

A- Allergies

M-Medications

P-Past pertinent medical history

L- Last oral intake, last menstrual cycle

E-Events leading to present illness/ Injury