Principles of history taking

Reviewing the Chart:  The medical chart give you valuable information about past diagnosis and treatment  You should look at the identifying data (age, gender, address, marital status, health insurance, the medication list, the documentation of allergies)

Clinician’s Behaviors  As you observe the patient throught the interview, the patient will be watching you  You should be sensitive to those messages and manage them as well as you can  Posture, gesture, eye contact, and words can express interest, attention, acceptance, and understanding  The skilled interviewer seems calm and unhurried, even when time is limited

Clinician’s Appearance Cleanliness, neatness and a name tag are reassuring to the patient. Remember that you want the patient to trust you

Note taking You need to write down much of what you learn in a health history The Enviroment Make the setting as private as possible

Learning about the Patient’s iIlness Greeting the Patient  Greet the patient and introduce yourself by name  If this is the first contact, clarify your role, such as stating your status as a student and explaining your relation to the patient’s care  When other individuals are present, ask the permission of the patient to conduct the interview in front of them

The Patient’s Comfort Be alert to the patient’s comfort

Comprehensive history  Data and time of history: the date is important  Identifying data: including age, gender, maritual status and occupation  Source of history: such as patient, family, friend, officer, consultant, medical record  Chief complaints

Comprehensive history  Present illnes  Current medication: including dose and frequency of use  Allergies  Past history  Childhood illnesses: such as measles, rubella, mumps, whooping cough, chicken pox, rheumatic fever, polio

Comprehensive history  Adult illnesses: Medical 1.Diabetes mellitus 2.Hypertension 3.Hepatitis 4.Asthma 5.HIV

Comprehensive history  Adult illnesses: Surgical: include dates, indication, outcome Obstetric/ Gynecologic: inculde obstetric history, menstruation history, birth control, number and gender of partners, at-risk practises Psychiatric: include dates, diagnosis, hospitalisations, treatment

Current health status Tobacco (type used, amount and duration of use)  Alcohol (type used, amount and duration of use)  Drugs (type used, amount and duration of use)

Current health status  Exercise and diet  Immunisations: 1.Tetanus 2.Pertussis 3.Diphteria 4.Polio 5.Measles 6.Rubella 7.Mumps 8.Influenza 9.Hepatitis B

Family history Age and health, or age and couse of death of each immediate family members (parents, siblings, spouse, and children)  Date of grandparents and grandchildren may also be useful

Family history  Diabetes mellitus  Heart disease  Hypercholeterolemia  High blood pressure  Stroke  Kidney diseases

Family history  Arthritis  Anemia  Allergies  Asthma  Headaches  Mental illness

Family history  Tuberculosis  Cancer  Drugs  Epilepsy

Personal and Social History  Occupation and education  Home situation  Daily life  Leisure activites/hobbies

Present illness The principal symptoms should be discribed in terms of: 1.Location 2.Quality 3.Quantity and severity 4.Timing 5.Factors that have aggrevated or relieved them

Review of systems General:  Weight, recent weight change  Weakness  Fatique  Fever

Review of systems Skin:  Rashes,  lumps,  sores,  itching,  dryness,  color change  Hair and nails changes

Review of systems  Head: headache, head injury, dizziness  Eyes: vision, glasses, contact lenses, pain, redness, dryness, double vision, spots, flashing lights, glaucoma, cataracta  Ears: hearing, vertigo  Nose an sinuses: frequent cold, nasal stuffiness, hay fever, sinus trouble

Review of systems  Mouth and throut: condition of teeth, gums, bleeding gums,sore tonque, dry mouth, frequnt sore throats, hourseness  Neck: lumps, „swollen glands”,goiter pain  Breast: lumps, pain and discomfort  Respiratory: cough, sputum (color quantity) hemoptysis, dyspnea, wheezing, asthma, bronchitis, emphysema, pneumonia, tuberculosis,

Review of systems Cardiac:  heart trouble,  high blood pressure,  rheumatic fever,  heart murmurs,  chest pain or discomfort,  palpitations, dyspnoe, orthopnoe, paroxysmal nocturnal dyspnoe, edema

Review of systems Gastrointestinal:  Trouble swallowing  Heartburn  Appetite  Nausea  Vomiting  Regurgitation  Vomiting of blood

Review of systems Gastrointestinal: Bowel movements Color and size of stools Change of bowel habits Rectal bleeding Black tarry stools HemorrhoidsConstipationDiarrhea

Review of systems Gastrointestinal: Abdominal pain Food intolerance Jaundice Liver or gallbladder trouble hepatitis

Review of systems Urinary:  Frequency of urination  Polyuria  Nocturia  Burning or pain on urination  Hematuria  Urgency  Reduces caliber or force if the urinary stream  Incontinece  stones

Review of systems Genital: Female:  Age at menarche  Regularity  Frequency  Duration of periods  Amount of bleeding  Last period

Review of systems Genital:Femal:  Dysmenorrhea  Premenstrual tension  Age at menopausa  Itching  Sexually transmitted diseases  Number of pregnanycies  Number and type of delivery  Number of abortion

Review of systems Genital:Male:  Hernias  Testicular pain  Sexually transmitted diseases

Review of systems Periferla vascular:  Intermitten claudication  Leg cramps  Varicose veins  Past clots in the veins

Review of systems Musculoskeletal:  Muscle pain, weakness  Joint pain  Stiffness  Arthritis  Gout  Backache

Review of systems Neurologic: 1.Seizeres 2.Weakness 3.Paralysis 4.Numness or loss of sensation 5.Tremor

Review of systems Hematologic  Anemia  Easy bruising or bleeding  Past transfusion

Review of systems Endocrine  Thyroid trouble  Heat or cold intolerance  Excessive sweating  Diabetes  Excessive thirst or hunger  polyuria

Establishing Rapport  The initial contact with the patient sets the foundation for the relationship  Good interviewing technique allows patients to recount their own stories spontaneously  You should listen actively and watch for clues to important symptoms, emotions events, and relationships  You can than guide the patient into telling you more about the areas that seem most significant.  This is done by using direct questioning  Questionts should proceed from the general to the specific

 Sometimes patients seem quite unable to describe their symptoms without help  Offer multiple-choice answers” Is your pain aching, sharp, pressing, burning, shooting, or what?  Use lanquage that is undestandable and appropiate to the patient  Establishing the sequence and time course of the patient’s symptoms is important  You can encourage a chronologic account by such questions as” What than?” or „What happened next?”

Generating and Testing Diagnostic Hypotheses  As you learn about the patient’s story and the symptoms, you should be generating hypotheses about what body systems might be involved by a pathologic process  For example, leg pain, suggests a problem in the peripheral vascular, musculoskeletal, or nervous system

 1. Its location.Where is it? Does it radiate?  2. Its quality. What is it like?  3. Its quantity or severity. How bad is it?  4. Its timing. When did or does it start? How long does it last? How often does it come?  5. The setting in which it occurs, including enviromental factors, personal activities, emotional reactions.  6. Factors that make it better or worse.