History Taking Dr K T Sundaresan Consultant Physician Teaching Hospital Batticaloa

Introduction It is the art and science of communicating effectively with the patient A critical phase of the clinical examination

History-takingInformation gathering ExaminationObjective findings History taking is the first and most important phase of a clinical examination

Importance Crucial part of clinical examination Provides a lot of diagnostic information Provides basis for priorities in clinical examination, investigations to be done, and management

Assets valuable in obtaining a good history Be courteous and patient Appear interested and attentive Encourage questions Be friendly Dress smart

Parts of history taking Basic details (age, sex, marital status, nationality, occupation) Presenting complaint (PC) History of presenting complaint (HPC) Review of systems Past medical history (PMH) Drug history (DH) Allergic history Family history (FH) Menstrual history Social history (SH) Further information from a third party

Interview technique Introduce yourself Avoid technical terms, use simple language Start with open inquiries (general questions) What brings you to hospital? What happened next Tell me about your pain What effects has this illness had on your life?

Interview technique Then move to closed inquiries (specific questions and clarifications) When did your headache begin? Have you had chest pain? Has any one in your family had a similar problem?

Parts of history taking Basic details (age, sex, marital status, nationality, occupation) Presenting complaint (PC) History of presenting complaint (HPC) Review of systems Past medical history (PMH) Drug history (DH) Allergic history Family history (FH) Menstrual history Social history (SH) Further information from a third party

Presenting complaints Examples Chest pain Shortness of breath Leg swelling Head ache Arm weakness …

Parts of history taking Basic details (age, sex, marital status, nationality, occupation) Presenting complaint (PC) History of presenting complaint (HPC) Review of systems Past medical history (PMH) Drug history (DH) Allergic history Family history (FH) Menstrual history Social history (SH) Further information from a third party

History of present illness Till when were you in good health? Please tell me what has happened to you since then Patient should be allowed to give history with minimum interruption (“so what happened next?”)

Pain, a common presenting complaint Location Radiation Duration Onset Character Severity Course Aggravating factors Relieving factors

Pain: associated symptoms Faintishness Sweating Nausea Vomiting

Read ! Headache Abdominal pain

Parts of history taking Basic details (age, sex, marital status, nationality, occupation) Presenting complaint (PC) History of presenting complaint (HPC) Review of systems Past medical history (PMH) Drug history (DH) Allergic history Family history (FH) Menstrual history Social history (SH) Further information from a third party

sytemic inquiry A thorough inquiry of cardinal symptoms of all major body systems is important for excluding disease in organs other than the major affected system

General health General well being Sleep Appetite Weight change

CVS Chest pain on exertion Breathlessness when lying flat (orthopnoea) Attacks of breathlessness at night (Paroxysmal nocturnal dyspnoea) PND Ankle swelling Palpitations

Respiratory system Shortness of breath Wheezing Cough Sputum production (color, amount) Chest pain related to respiration or coughing Blood in sputum (haemoptysis)

Alimentary system Difficulty in swallowing Nausea and vomiting Indigestion Heartburn Abdominal pain Change in bowel habit Color of motion (pale, dark, black, fresh blood)

Urogenital Pain on passing urine Frequency of passing urine by day or night Abnormal color of urine Symptoms of enlarged prostate if appropriate Sexual history if appropriate

Central nervous system Headaches Fits Faints and blackouts Tingling or numbness Muscle weakness Deafness or tinnitus Double or blurred vision

Musculoskeletal Joint pain, stiffness or swelling Muscle pain or weakness Backache

Endocrine Heat intolerance Cold intolerance Change in sweating Prominence of eyes Swelling in neck Excessive thirst, hunger, urine Weight

Parts of history taking Basic details (age, sex, marital status, nationality, occupation) Presenting complaint (PC) History of presenting complaint (HPC) Review of systems Past medical history (PMH) Drug history (DH) Allergic history Family history (FH) Menstrual history Social history (SH) Further information from a third party

Past medical history (PMH) What significant illnesses have you had? Only illnesses that are clinically significant and potentially relevant are important, e.g. Hemoptysis: tuberculosis Chest pain: IHD Document comorbidities e.g. diabetes, IHD, hypertension, bronchial asthma, osteoarthritis, etc.

Parts of history taking Basic details (age, sex, marital status, nationality, occupation) Presenting complaint (PC) History of presenting complaint (HPC) Review of systems Past medical history (PMH) Drug history (DH) Allergic history Family history (FH) Menstrual history Social history (SH) Further information from a third party

Drug history Obtain full details: Name of each drug Dose Frequency Duration of treatment Side effects Compliance

Allergic history Drugs and food

Parts of history taking Basic details (age, sex, marital status, nationality, occupation) Presenting complaint (PC) History of presenting complaint (HPC) Review of systems Past medical history (PMH) Drug history (DH) Allergic history Family history (FH) Menstrual history Social history (SH) Further information from a third party

Family history (FH) Tell me about any illnesses that run in your family? Many disorders may have a genetic basis: Autosomal dominant Autosomal recessive Sex linked Multifactorial

Pedigree charts Pedigree charts show a record of the family of an individual. These can be used to study the transmission of a hereditary condition.

Symbols used in pedigree charts

Pedigree chart example In a marriage with five children, two daughters and three sons. The second son is affected by the condition.

Pedigree chart of four generations Generations are identified by Roman numerals. Individuals in each generation are identified by Arabic numerals numbered from the left. Therefore the affected individuals are II3, IV2 and IV3.

Parts of history taking Basic details (age, sex, marital status, nationality, occupation) Presenting complaint (PC) History of presenting complaint (HPC) Review of systems Past medical history (PMH) Drug history (DH) Allergic history Family history (FH) Menstrual history Social history (SH) Further information from a third party

Menstrual history Age of onset of periods Regularity of periods Duration of bleeding Date of last period Contraception if relevant

Parts of history taking Basic details (age, sex, marital status, nationality, occupation) Presenting complaint (PC) History of presenting complaint (HPC) Review of systems Past medical history (PMH) Drug history (DH) Allergic history Family history (FH) Menstrual history Social history (SH) Further information from a third party

Social history Alcohol Tobacco Illicit drugs Dietary habits Pets Home or family environment Schooling Mobility (elderly)

Tobacco smoking Smoker, ex-smoker, life-long non-smoker? Form: cigarettes, “beedy” Quantity Duration (Pack years) 1 pack year is equal to smoking 1 pack (20 cigarette) per day for 1 year Example: If a person smokes 30 cigarettes a day for 40 years, then we would calculate as follows: 30 Cigarettes a day = 1.5 packs a day (20 cigarettes in a pack)

Alcohol Calculate weekly intake in units Method 1 Standard measure = one glass of wine, 250 ml of beer, 25 ml small drink of spirits = 1 unit Safe limits Male 21units/week Females 14 units/week

Detailed alcohol history If excessive drinking suspected: Quantity and type of drink Alone or accompanied Amount of money spent on alcohol Presence of binge drinking Presence of morning drinking

A Screening Test for Alcohol Dependence CAGE Questionnaire Felt the need to Cut-Down drinking Felt Annoyed by criticism re. drinking Guilty feels about drinking Ever drank first thing in the morning Eye-opener

Alcohol related problems Problems at work (e.g. dismissal) Problems with personal relationships (e.g. divorce, domestic violence) Problems with the law (e.g. drunken driving) Psychological problems (e.g. depression, insomnia, attempted suicide)

Illicit drug use (substance misuse) Type(s) of drugs involved (e.g. cocaine, heroin, amphetamines, pethidine) Frequency & duration of use Intravenous use, needle sharing Drug dependence Any physical, mental or social problems

Dietary history 24 hour recall: what did you eat yesterday? Typical intake pattern: What do you normally eat during the day? vegetarian

Third party information If patient is withholding information Patient too unwell Mental incapacity Communication difficulties, e.g. deafness, speech disorders, emotional problems Children

Parts of history taking Basic details (age, sex, marital status, nationality, occupation) Presenting complaint (PC) History of presenting complaint (HPC) Review of systems Past medical history (PMH) Drug history (DH) Allergic history Family history (FH) Menstrual history Social history (SH) Further information from a third party

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Short notes Summary problem list Timing