History taking remains important

Since many students find difficulty in taking a systematic and complete  medical history, especially within the first few weeks of  clinical teaching program, I summarize here a simplified guide to history taking that would be extremely useful.
Next posts will include a guide to general examination for 4th year students.
Fifth year students will find some useful posts. I am preparing for them a lecture of how to interpret ECG in a very simple way.

 

A Guide For History Taking

Patient's personal data : name, age, sex , nationality, religion, and residence.

Presenting (Chief) complaint(s ): 

Symptom(s) in chronological order + duration.

eg:  Fever for 7 days, productive cough for 5 days, and breathlessness for 2 days.

i.e arrange symptoms according to their  duration. The first symptom to be mentioned first, and the most recent symptom to be last.

History of the presenting (chief) complaint(s):

Start analyzing the symptoms one by one in detail , mentioning any associated symptoms.

Use the patients own words.

It is very useful to let the patient to describe in detail what happened.

Details of the circumstances during the onset of symptom(s), especially for acute symptoms, will make the history more clear than getting short and vague history with many gaps.

Ask about other symptoms related to the main affected system(s), which shouldn't be mentioned later on in the review of systems.

Sometimes symptoms are related to two systems with no clear distinction  (eg cardiovascular and respiratory). In this case, you should cover both systems in the history of the presenting complaints.

Ask about generalized symptoms, which may be related to any of the body systems. These include : change in weight, change in appetite, lumps (which may be enlarged lymph nodes), fatigue, itching, fever, night sweats, and skin rash.

Ask about any change in symptoms throughout the course of the illness. Ask about any recent or past similar illness (?remitting and relapsing disease).

Systemic review:

CVS:                                                                                                                                                                                                                                    Chest pain, breathlessness, Orthopnea, PND, palpitations, cough, hemoptysis, wheeze ( this may be a symptom of left-sided heart failure), ankle swelling and intermittent claudication.

Respiratory:

Chest pain, breathlessness, cough (dry or productive), sputum texture (thin or thick), and amount, hemoptysis, wheeze, hoarseness of voice.

GIT:

Mouth ulcers, appetite, weight change, dysphagia, odynophagia, abdominal pain, nausea, vomiting, hematemesis, abdominal distention, change in bowel habit, rectal bleeding, melena, jaundice, pruritus, dark urine, pale stools.

G.U:

Loin pain, fever, incontinence, dysuria, hematuria, nocturia, frequency, polyuria, oliguria, hesitancy, terminal dribbling, urethral discharge, vaginal discharge, menses(frequency, regularity, heavy or light, dysmenorrhea, first day of the last menstrual period). Number of pregnancies, menopause.

Locomotor:

      Joints : Pain, swelling, pattern of distribution, morning stiffness, loss of function.

      Extra-articular : Rashes, photosensitivity (This may indicate anterior uvietis) ,Raynaud's phenomenon , alopecia, dry mouth, dry eyes, red eyes, lumps/nodules, mouth ulcers, genital ulcers.

Nervous system:                                                                                                                                                                                                                                                                  Headache,  visual symptoms, decrease or loss of hearing, smell, and taste, difficulty in speech, difficulty swallowing, pain, numbness, paresthesia (tingling, pins and needles, and burning sensation), weakness, balance, sphincter control, involuntary  movements, fits, faints, and loss of consciousness.

Endocrine:

Hot or cold intolerance, neck swelling, and change in weight.

Past Medical History:

Chronic disease(s) eg DM, hypertension, bronchial asthma…etc. What and when was the first presentation?

Past hospital Admission(s) :When? What was the reason for admission? (any specific diagnosis).

Duration of stay in hospital, any specific diagnostic and/or therapeutic interventions, any complications of disease or therapy, condition at discharge, and any specific advices given to the patient.

Past illnesses which were treated on outpatient basis.

Past Surgical History:

Surgical operation(s) and blood transfusion.

Post-operative complications

Anesthetic problems ( due to general anesthesia)

Drug history:

Prescribed :Tablets, capsules, inhalers, injections, or topical : names, frequency of administration, any side effects or complications, compliance, and if  non-compliant check for the reasons.

Over-the counter (OTC) drugs

Drug allergies

Herbal remedies

Family history:

History of similar illness in parents or kids (?autosomal dominant disease).

History of any disease running in the family or second degree relatives eg : Diabetes

and hypertension.

Social history:

Marital status.

Educational level

Employed, retired or unemployed

Family size

Income

Home conditions: Which floor? Well ventilated and exposed to sun light or not?

Contact with pets.

How does the patient cope with his/her disease regarding ordinary daily activity.

Dependence on others for self-care

Work conditions:   

Job, and nature of work.

Previous job(s)

Any exposure to environmental hazards (chemicals, dust, noise…etc)

Contact with ill persons.

Do the presenting symptoms improve on holidays? (eg occupational asthma)

Does his/her illness affect his/her job? (need for sick leaves)

Personal habits:

Active or passive smoker (or none)

Alcohol use

Tobacco chewing

Recreational drugs (drug abuse)

Travel history:

Where, when and how long was the trip (and reason for)

Any illness(es) while abroad or shortly after return

Recommended readings :

-          Macleod's Clinical Examination.

-          Davidson's Principles and Practice of Medicine