1. Dr. W.C.Lwabby Ass. Lecturer int. med. Dpt
HISTORY TAKING
Dr. W.C.Lwabby
Ass. Lecturer int. med. Dpt

2. It is both a science and an art.
It depends on the department you are.
Eg: history in Paediatrics may be taken differently from the one in psychiatry.
Time and weight will be determined by the type & number of pt you are having.

3. PATIENT IDENTIFICATION
Name, preferably 3 names
Age, both date of birth and age
Sex
Residence/address
Religion
Tribe
Marital status
Level of education
Occupation
Next of kin

4. Referral If self referral or from another hospital
If referred from another hosp when and why (reason for referal).

5. Chief complaint Some call it main/pt complaint
This is what brought the pt to the hospital (what made a pt to seek medical care)
There may be only one or more than one complain(s)

6. They should be arranged in chronological order starting with the one which has longer duration.
Eg:
abdominal pain for 6 days
diarrhoea for 4 days
vomiting for 2days

7. History of presenting illness (HPI)
Here is where the amplification of the complaints is done.
It includes the:
Duration-how long has pt been having complain
Onset of the complaint-gradual, sudden, progression
Periodicity-more at which time of the day
Aggravated factors
Relieving factors
Associated factors

8. The HPI should be Focused, Searching and goal oriented.
Site, radiation, character and severity in case of pain
The HPI should be Focused, Searching and goal oriented.
At the end of HPI you should have at least 50% of your diagnosis.

9. Review of other systems
Other systems which are not affected, have not been touched in HPI.
You may find a system which is affected but it is not of pt importance.
Any positive history has to be taken back to HPI and should be amplified.
It should have only negative findings

10. ENT: discharge, hearing impairment, painful swallowing.
NS: convulsions, LOC, blurred vision,headache,numbness.
Resp: cough, chest pain, wheezing.

11. CVS: easy fatigability, DIB, heartbeats awareness
GIT: vomiting, diarrhea, constipation
Urinary: painful, increase frequency of micturation
Genital: itching, ulceration, swelling,discharge.
Musculoskeletal: joints/muscle pain

12. Past medical history Hx of previous admission/attending OPD
No. of previous admissions/attending OPD, when, where and why?
If admitted, for how long before being discharged, any surgery and hx of blood transfusion.

13. Working diagnosis and management given (investigations done and treatment given)
Drug/food allergy.
History of Chronic Illnesses such as HTN,DM e.t.c.

14. Family-social history
Number of siblings
Parents and their occupation
Hx of inherited diseases (SCD, HTN, Asthma, Epilepsy)
Alcohol/cigarette use

15. Sexual history If sexually active Number of sexual partners
Use of protection

16. Substance-use history
Substance includes alcohol, cigarette, heroin, cocaine, etc
Alcohol: type (local/beer), amount, how frequent
Cigarette: number/day, how frequent
Heroin/cocaine: route, amount, how frequent
cannabis: type, route, amount, how frequent

17. Personal history Schooling Occupation
If married, hx of a wife (age, education, occupation)
Number of children and their age

18. Menstrual history When attained puberty? Duration of menstruation
Duration of a cycle
Amount of blood/day
Nature of blood
Any accompanied abdominal pain.

19. Contraceptive history
Type
Duration
Any side effect

20. Obstetric history Number of children Mode of delivery
Any complications (prenatal, natal and post-natal)

21. Gynaecological history
Hx of STD (hx of abnormal vaginal discharge, genital ulcer)
Hx of gynaecological surgery

22. Nutritional/diet history
Type of diet
Number of meals
How frequent
Amount

23. THANK YOU