Basic History and Physical Taking

1. Basic Clinical Skills
1

2. Outline
• History taking
• Physical examination
2

3. INTRODUCTION
• Complete medical evaluation includes
• Medical History → Symptom
• Physical examination → Sign
• Appropriate laboratory or imaging studies
• Analysis of data
• Diagnosis
• Treatment plan
3

4. History Taking
• Description: a report that includes information gained from a
patient's medically relevant recollections.
• Objectives
• Establish a good physician-patient relationship
• Precise documentation of symptoms
• Develop a differential diagnosis
4

5. History Taking
• Optimal setting
• Uninterrupted environment: a quiet room without other patients, if possible
• Only the patient should be present, unless:
• Patient’s Request
• Children
• Special conditions: E.g. language barrier (Interpreter need)
5

6. History Taking
• Key Elements: The “Classic” History Taking Sequence
1. Identification
2. Previous Admission
3. Chief Complaints
4. History of Present Illness
5. Past Illness
6. Family History
7. Social & Personal History
8. Functional Inquiry (System Review)
9. Additional targeted questions depending on the patient
6

7. History Taking
• Key Elements: The “Classic” History Taking Sequence
1. Identification
• Full Name
• Age
• Sex
• Address
• Date
• Hospital/Card number
• Occupation
• Religion
• Marital status
• Ethnicity/Race
7

8. History Taking
• Key Elements: The “Classic” History Taking Sequence
2. Previous Admission
• List of hospitalization in the order they occurred
• Include:
• Specify the date
• Name and location of the hospital
• Disease that led to admission
• Outcome as briefly as is possible
• E.g.: 1990 (EC). Menilik II Hospital, Addis Ababa. Bleeding duodenal ulcer. Discharged
symptom free after transfusion of 2 units of blood.
8

9. History Taking
• Key Elements: The “Classic” History Taking Sequence
3. Chief Complaints
• The main reason for the patient's visit
• It should include:
• The complaint
• Duration of the complaint
• If more than one complaint, they should be listed in the order of occurrence.
9

10. History Taking
• Key Elements: The “Classic” History Taking Sequence
3. Chief Complaints
• While recording chief complaint,
• It should be clearly in the patient's own words, e.g., "knee hurts,” “upset stomach,” “runny
nose.”
• The first question should be as open as possible in order to enable the patient to freely
describe their concerns. Examples include:
• ”How may I help you?”
• ”What brings you here today?”
10

11. History Taking
• Key Elements: The “Classic” History Taking Sequence
4. History of Present Illness
• Date of onset
• Mode of onset and progression.
• Abrupt vs gradual
• Constant vs intermittent
• Character and location
• Exacerbating and relieving factors
• Effect of Treatment
• “Negative-positive” Statements
• How they came to the hospital
The OPQRST of Pain:
O – Onset
P – Provocation and
palliation
Q – Quality
R – Region and
Radiation
S – Severity
T - Timing
11

12. History Taking
• Key Elements: The “Classic” History Taking Sequence
5. Past Medical History
• Listing of illnesses unrelated to the present illness, experienced in the past including:
• Childhood diseases
• Serious injuries and surgery not requiring hospitalization
• Medications and Allergies should also be sought.
• Mention of each disease with an approximate date, severity, duration, complications and
sequelae (consequences) is essential
12

13. History Taking
• Key Elements: The “Classic” History Taking Sequence
6. Family History
• Father and mother: Age, health, date and cause of death.
• Siblings: List with ages, health (if dead, mention cause of death)
• Family disease: Tuberculosis, diabetes mellitus, hypertensive disorders, migraine.
13

14. History Taking
• Key Elements: The “Classic” History Taking Sequence
7. Social & Personal History
• Early development: place of birth and early homes, childhood development, health and
activities, social and economic status.
• Education: School history, achievements and failures.
• Social activities: Recreation and other activities
• Work record: Age begun, type of work, number of jobs, industrial hazards and exposures,
present work.
• Environment: living conditions.
• Habits: Dietary, alcohol, tobacco, drugs, herbs.
• Marital status: Health of wife (or husband), adjustment, number of children and their health.
14

15. History Taking
• Key Elements: The “Classic” History Taking Sequence
8. Functional Inquiry (System Review)
• A list of questions, arranged by organ systems, to help establish the causes of signs and
symptoms
• Goals:
• Systematic approach to establish the correlation of symptoms to organ systems
• Identifying potential or underlying concerns that the patient did not report while taking an
HPI or PMH
• Establishing positive and negative organ-specific findings
15

16. Functional
Inquiry
(System
Review)
16

17. History Taking
• Key Elements: The “Classic” History Taking Sequence
9. Additional targeted questions depending on the patient
• Obstetrics and Gynecological History
• Pediatrics
• Surgery
• Psychiatric History
17

18. History Taking
• Key Elements: The “Classic” History Taking Sequence
9. Additional targeted questions depending on the patient
• Obstetrics and Gynecological History:
• Menstrual/Menopausal History: Age at Menarche, Date of Last Menstrual Period, Duration,
History of postmenopausal vaginal bleeding
• Sexual History: Current/past sexual partners, Current/past sex practices, Current/past
contraceptive methods, History of Sexually transmitted infections
• Obstetrics History: Gravida (Number of birth), Mode of Delivery and details of the birth,
Pergnancy (Term, Preterm, Postterm; Trimester of Pregnancy), Abortions
18

19. History Taking
• Key Elements: The “Classic” History Taking Sequence
9. Additional targeted questions depending on the patient
• Obstetrics and Gynecological History:
• Patients may be hesitant to disclose certain aspects of their gynecologic history because of
the sensitive nature of the topic.
• In some cases, it may be due to cultural differences or even a history of abuse.
• If you feel that the patient is uncomfortable talking about their gynecologic history, start with
a social or family history in order to establish rapport with the patient
19

20. History Taking
• Key Elements: The “Classic” History Taking Sequence
9. Additional targeted questions depending on the patient
• Pediatrics
• In addition to the details of a general medical history, there are some notable differences to
be aware of when taking a pediatric medical history, including
• Certain patient details,
• The source of information, and
• Modes of communication.
20

21. History Taking
• Key Elements: The “Classic” History Taking Sequence
9. Additional targeted questions depending on the patient
• Pediatrics
• In addition to the details of a general medical history, there are some notable differences to
be aware of when taking a pediatric medical history, including
• Certain patient details,
• The source of information, and
• Modes of communication.
❑ Prenatal and birth history (History of related to
pregnancy and birth)
❑ Developmental history (in those aged <3 years
ask about age specific milestones)
❑ Further social history details (Nutritional
History)
❑ Immunization history
21

22. • Developmental
Milestones
22

23. History Taking
• Key Elements: The “Classic” History Taking Sequence
9. Additional targeted questions depending on the patient
• Pediatrics
• In addition to the details of a general medical history, there are some notable differences to
be aware of when taking a pediatric medical history, including
• Certain patient details,
• The source of information, and
• Modes of communication.
❑ Involvement of Parents/Guardian specially in
lower age groups
23

24. History Taking
• Key Elements: The “Classic” History Taking Sequence
9. Additional targeted questions depending on the patient
• Pediatrics
• In addition to the details of a general medical history, there are some notable differences to
be aware of when taking a pediatric medical history, including
• Certain patient details,
• The source of information, and
• Modes of communication.
❑ Always open the interview with casual conversation to
establish rapport between you and the child or
parents/guardian.
❑ Begin the medical portion of the interview by taking
the social history before addressing the current health
concern.
❑ Observe parent-child interaction, and always be
vigilant regarding signs of potential child neglect or
maltreatment.
24

25. History Taking
• Key Elements: The “Classic” History Taking Sequence
9. Additional targeted questions depending on the patient
• Surgery
• Previous Hospitalized Surgical History (with details)
• Allergies:
• Drug allergies and allergies to iodine (used for sterilization), latex (contained in gloves),
and other materials the patient might come in contact with during or after a procedure
(e.g., allergies to metals relevant for implants)
• Medication: Do not forget to ask about anticoagulants.
25

26. History Taking
• Key Elements: The “Classic” History Taking Sequence
9. Additional targeted questions depending on the patient
• Surgery
• Ask about anything that could lead to complications during anesthesia, e.g.:
• Cardiovascular and pulmonary diseases
• Smoking and alcohol
• If the patient needs emergency surgery: Ask when they had their last meal and which
medication(s) they took today.
• Ensure that the patient is authorized to give their consent for procedures (see also informed
consent).
26

27. History Taking
• Key Elements: The “Classic” History Taking Sequence
9. Additional targeted questions depending on the patient
• Psychiatric History
• History of psychiatric conditions (various mental disorders, which affect mood, cognition, perception, and behavior).
• Previous psychiatric hospitalization: when, where, and why
• Use of psychotropic medications: drugs, dosages, effectiveness, and side effects
• Suicide attempts or self-harm: why, when, how
• Past medical records available to consult
• History of substance use/abuse
27

28. References
• Amboss (https://www.amboss.com/)
• Harrison's principles of internal medicine. (2015). New York :McGraw
Hill Education
28