Medical Students - Internal Medicine / Medicine 1 History Taking

1. CURRENT HEALTH STATUS
SEMASINGHE, SUDHEERA W.
HISTORY TAKING & PHYSICAL EXAMINATION

2. • Current health status is an individual's relative level of
wellness and illness, taking into account the presence of
biological or physiological dysfunction, symptoms, and
functional impairment at the time of history taking & physical
exam by a doctor.
Health perceptions (or perceived health status) are subjective
ratings by the affected individual of his or her health status.
Some people perceive themselves as healthy despite suffering
from one or more chronic diseases, while others perceive
themselves as ill when no objective evidence of disease can be
found.

3. • Current Health Status focuses on the present state of
health and on environmental conditions, personal habits,
and health-related measures that may impinge it.
• Although some of the variables grouped under this
heading have past as well as current components, they all
have potential impact on current health and possible health
related interventions.

4. • Chronic diseases such as type 2 diabetes, heart
disease, arthritis and the like are a massive,
escalating global health problem, affecting millions
of lives everywhere and people are blissfully
unaware that they are suffering from these
diseases because they do not present outward
symptoms and they don’t feel ill.

5. COMPONENTS OF CURRENT HEALTH
STATUS
• Allergies
• Immunizations
• Screening tests
• Environmental hazards
• Use of Safety Measures
• Exercise and Leisure Activities
• Sleep Patterns
• Diet
• Current Medications
• Tobacco, Alchohol and Drugs

6. ALLERGIES
• The most important part of an allergy
investigation is taking a very detailed case
history, always including the family history,
because if many family members also have
allergies then the patient’s problems are also
more likely to be due to allergy.

7. IMMUNIZATIONS
Some important immunizations;
• Tetanus
• Diphtheria
• Polio
• Measles
• Rubella
• Mumps
• Hepatitis B

8. SCREENING TESTS
• Should be appropriate to the patient’s age.
• Results should be presented to the doctor with the dates they
were performed.
• Hematocrits
• Urinalyses
• Tuberculin tests
• Pap smears
• Mammograms
• Cholesterol tests

9. ENVIRONMENTAL HAZARDS
• Home, school or workplace

10. USE OF SAFETY MEASURES
• Seat belts
• Foot wear
• Eye wear

11. EXERCISE AND LEISURE ACTIVITIES
• How often does the patient exercise?
• What sort of work does the patient do?
• Have they always done the same thing?
• Do they enjoy it?
• If retired, what do they do to stay busy?
• Any hobbies?
• Participation in sports or other physical activity?

12. SLEEP PATTERNS
• Includes times that the person goes to bed and
awakens, daytime nap, any difficulties in falling sleep.

13. DIET
• Includes all dietary intake for a recent 24-hour period,
and any dietary restrictions and supplements.
• Questions should be direct and specific. For example;
“What did you eat first? Followed by?”
• Ask about intake of coffee, carbonic acid drinks, citric
acid drinks, tea, energy drinks and so on.

14. CURRENT MEDICATION
• Include;
• Prescribed medications
• Nom-prescribes medications
• Herbal medicines
• Medication sent from abroad
Note down dosages and time of intake.
This can provide critical information as frequently what appears to be a failure
to respond to a particular therapy is actually non-compliance with a prescribed
regimen.

15. TOBACCO, ALCOHOL & DRUGS
• Include the type, duration and amount used.
• Ask about number of bottles, no. of shotglasses, size of bottles
etc.
• how many packs per day and for how many years? If they quit,
when did this occur?
Avoid being judgmental, as it is not the physician’s job to do so.

16. OTHER
• Obstetric (where appropriate): Have they ever been pregnant? If so, how many
times? What was the outcome of each pregnancy (e.g. full term delivery; spontaneous
abortion; therapeutic abortion).
• Sexual Activity: This is an uncomfortable line of questioning for many practitioners.
However, it can provide important information and should be pursued.
• Do they participate in intercourse? With persons of the same or opposite sex? Are they
involved in a stable relationship? Do they use condoms or other means of birth
control? Married? Health of spouse? Divorced? Past sexually transmitted diseases? Do
they have children? If so, are they healthy? Do they live with the patient?
• Military Service: For obvious reasons, serving in the armed forces can be an important
period in someone's life. In addition, inquiring about physical trauma, mental health
issues (PTSD, depression, substance abuse), and unusual exposures (toxins, infections)
may reveal important information.

17. THANK YOU!

18. REFERENCES
• Bate’s Guide to Physical Exam and History Taking ; 10th edition
• http://qol.thoracic.org/sections/key-concepts/health-status-health-
perceptions.html