Taking a history and history components

1. The consultation
Taking a history
Dr. Abeer Abdulkareem

2. 1. History
2. Examination
3. Investigation
4. Management
Structure of the consultation :

3. Components in taking a medical history
• Introduction and details
• Presenting complaint
• History of present complaint
• Medical and surgical history
• Drug history
• Allergies
• Family history
• Social history
• Conclusion and closure

4. • You should always begin by introducing yourself.
• This should include your status as well as the educational reason for the encounter.
For example, “My name is... I am a... year medical student, and I have come to talk to you to
learn how to take a medical history.”
• obtain information about the patient including their name, age, marital status, and occupation.
• To establish rapport, and to put the patient at ease, consider these issues :
• How they would like to be addressed (forename or surname)
• Their physical comfort
• That you will treat all information as confidential
• How the patient may end the consultation: “If at any time you wish to stop this interview then
please let me know.”
Introduction and details

5. Presenting complaint
• Ask the patient to describe the symptom or problem that brought them to
hospital by using an open ended question:
• “What has happened to bring you to hospital?” or “What seems to be the
problem?”
• Clearly, you want answers but you wish to develop a rapport with the
patient as well as understand him or her (and you will not do this through
a series of closed questions).
• You should not interrupt.

6. • Let the patient describe in their own that has led to their present
situation.
• History taking involves the use of communication skills.
You need to develop your skills in:
• Opening and closing a consultation
• The use of open and closed questions
• The use of non-verbal language
• Showing respect
• Active listening
• Showing empathy

7. • This is not just an academic exercise
• Management of the patient is dependent on these aspects.
• If you do not communicate properly you will become increasingly
frustrated.
• So, when you are taking a history, listen to the patient.
• Do they know what is wrong with them?
• What are their concerns and expectations?

8. Complaint must be evaluated in detail.
• When did the problem start (date and time)?
• What initial action was taken by the patient (any self treatment)?
• When was medical help sought and why?
• What has happened since then?
• What investigations have been undertaken and what are planned?
• What action was taken by the health professional?
• What treatment has been given?

9. Often, the patient will complain of pain ASK ABOUT:
• Exact site or location of pain
• Nature of pain (dull, sharp, etc.)
• Onset of pain (sudden, gradual, etc.)
• Severity of pain (can use a scale 1-10)
• Duration of pain (seconds, minutes, hours, or days)
• Progress, including frequency and timing of the pain (constant, intermittent, etc.)
• Radiation of the pain
• Aggravating and relieving factors
• Previous occurrences
• Associated symptoms
• The patient's notion of what is causing the pain.
SOCRAAAT

10. • “Have you had any serious illnesses?”
• “Have you ever been admitted to hospital?”
• “Have you had any operations?”
The medical history is useful as it determines:
• Whether the patient has had this problem before
• What investigations were carried out and what diagnosis was made at that
time.
• What other problems the patient has
• The patient's understanding of his or her illness.
Medical and surgical history

11. Treatment and other drug history
• Prescribed drugs
• Over the counter treatments-that is, drugs bought without a prescription
• Herbal or “natural” treatment
• Illegal or “recreational drugs.”
• Ask the patient if they are on any treatment for each problem:
“Do you take anything for your arthritis?” and so on.
• The patient may have forgotten to tell you that he or she has hypertension,
and this is discovered only from the treatment and other drug history.

12. • Occupation, Marital status , Whether he or she has any children.
• Travel history (with illnesses such as avian flu, it is essential).
• Knowing the patient's interests allows a clinician to understand the patient better. This
assists the doctor-patient relationship and is vital to patient management.
• A more detailed history including ages, health and so on of children can be obtained where
relevant
• (For example, in the case of an elderly patient where a decision is to be made on when and
where he or she should be discharged).
• How many cigarettes a day and for how long?
• If the patient is a former smoker, when did they stop and how long had they smoked before
stopping?
• How much(per day) and for how long?
Social and occupational history
Smoking history

13. Be accurate: Care needs to be taken to obtain an accurate
history.
There is a tendency to underestimate the intake, so you
should separate weekdays and weekend intake.
You should also determine if there is a history of binge
drinking.
Get right to the point
This topic needs to be discussed in a non-judgmental way:
• “How much alcohol do you normally drink?
If no clear answer is given, ask along the lines of:
• “How much did you drink in the last week?”
Alcohol history

14. • Who has the problem? Is it a first or second
degree relative?
• How many family members are affected?
• What exactly is the problem?
For example, “heart problems” could be
several things:
Hypertension, Ischemia ,Valve problems…
• At what age did the relative develop the
problem? Clearly, early presentation likely
to be important than one presenting is more
later in life.
• You also need to ask if the parents are alive
and, if not, at what age they died and the
cause of death.
• Questions about the family history should
be obtained sensitively as they may bring
back distressing memories for the patient.
You should develop your own method of
putting the patient at ease.
• “If you don't mind, I would like to ask you
some questions about your family.”
• “How old are your parents?” And, “Are
they well?” And so on.
Family history

15. • The systems review is a series of questions linked to a system- cardio vascular,
respiratory, gastrointestinal, neurological, and so on It is:
• Helpful in determining if there are any concurrent diseases that the patient may have
(and which he or she may or may not be aware of).
• Relative importance
• It can also be considered a safety net which reduces the chances of missing an
important symptom or disease.
• However, it can lead to confusion and misdirect the clinician if the patient has
multiple symptoms or is garrulous.
Systems review

16. Practice and tailor it
In order for you to remember the relevant questions from each system, it
is important practicing using the systems review on each patient.
You should start with the most relevant system(s) to the presenting
complaint
A patient presenting with chest pain should initially be asked questions
about the cardiovascular and respiratory systems. The depth of these
questions depends on you, the patient, the illness, the circumstances,
and so on.

17. You will find that patients do not necessarily understand a particular
phrase. For instance, should you use “sputum” or “phlegm” when
considering the symptoms of cough? What does “going to the toilet”
mean? Likewise, a patient may not understand the term “myocardial
infarction” but be familiar with “heart attack.”. So:
• Practice using different terms and phrases until you find one that you are
comfortable with
• Always have a few alternatives ready
Language and understanding

18. Making closing statements
You can use different approaches:
• You should always thank the patient for his or her time and cooperation
• Ask the patient “Is there anything else that you wish to tell me?”
• Or, especially in exams (and with a warm smile): “Have I missed anything?”
Conclusion and closure

19. Summarization
• it is helpful to give a short summary of your understanding of the
problem or symptoms to the patient.
• This reduces the risks of misunderstanding.
• It is essential for proper management, especially in the case of new
patients and in those with complicated or multiple problems:
• “May I summaries my understanding (of what you have told me). You
presented on... with... You also had symptoms of... In the past, you
have had...” and so on.