history taking skills

HistoryHistory TakingTaking SkillsSkills

Grzegorz Chodkowski (MD)Grzegorz Chodkowski (MD)

Riga, Radisson SAS

2009

HistoryHistory TakingTaking FormatFormat

– Chief complaint

– History of present illness (HPI)

– Past medical history, which includes

• Childhood

• Medical

• Surgical

• OB/GYN

• Psychiatric

– Family history

– Medications

– Allergies

– Personal/social history

– Review of systems

Chief Chief complaintcomplaint

problem / condition that motivated patient to seek care

To elicit the chief complaint, ask broad questions:

– What brings you in today?

– Tell me what has been going on.

– What seems to be the problem?

– What are your complaints?

HistoryHistory ofof thethe presentpresent illnessillness (HPI)(HPI)

• Patient's age, sex, occupation

• Symptoms (or immediate cause of admission)

• Chronology and the seven characteristics of the current symptoms:

-Anatomic location

-Quality

-Quantity or severity

-Timing

-Setting in which the symptoms occur

-Aggravating or relieving factors

-Associated symptoms

HistoryHistory ofof thethe presentpresent illnessillness (HPI)(HPI)

Use facilitating expressions to encourage the patient to

continue:

– Mmm Hmm.

– Yes?

– Uh Huh?

– And what else?

- I am with you

– Listening body language

Once the patient has had a chance to tell his or her story you can move on to more directed questions to clarify.

• What is wrong?

• Where is it wrong?

• When did it start going wrong?

• How did it go wrong?

• Why do you think it is wrong?

DirectedDirected oror closedclosed questionsquestions

– Multiple choice

• Do you have nausea, vomiting, constipation ordiarrhea?

• Is the pain sharp, dull or shooting?

• Have you had this for days, weeks or months?

• How long is the pain: minutes or hours?

Important: Pause to wait for each response!!

YesYes oror NoNo questionsquestions• Do you have diarrhea every day?• Do you have any allergies?

QuantitiveQuantitive questionsquestions

• How many loose stools do you have a day?

Avoid leading questions

– You don’t smoke do you?

– You haven’t had any chest pain?

– Your wife is your only sexual partner, right?

Avoid compound questions

– Do you have trouble sleeping?

How much sleep do you get?

– Do you use cocaine, marijuana or alcohol?

RememberRemember !!

L : Location

O : Other symptoms

C : Characteristic of the symptom

A : Aggravating or alleviating factors

T : Timing

E : Environment

S : Severity

MnemonicsMnemonics

LocationLocation

• Where does it hurt?

• Which part of your chest/head/abdomen is

affected?

• Does it stay in one place or does it radiate

anywhere else?

OtherOther symptomssymptoms

� Pertinent positives and negatives to help

you rule in or rule out disease

� Associated symptoms

� Other new symptoms that may not be

related

OtherOther symptomssymptoms

- questions

• Apart from your chest problem are there any other problems

• How’s your appetite?

• Do you have any problems with passing water?

• Are your bowel motions regular?

• Have you noticed any blood in your stools?

CharacteristicsCharacteristics

-quality of the symptom

Get the patient to use their own descriptive words if possible.

– What does it feel like?

– What kind of pain is it?

– Can you describe the pain?

– Does it affect your sleep/work?

– How often are the attacks?

– Is the pain continuous or does it come and go?

– What makes it better?

– What makes it worse?

– What has the patient done to try to feel better?

– What seems to bring the pain on?

– Does anything make it better / worse ?

– Is the pain relieved by drugs / rest / changing position?

– Have you taken any medicines for the pain?

(over the counter medications, friend’s medication)

AggravatingAggravating AndAnd AlleviatingAlleviating FactorsFactors

Timing: Timing: OnsetOnset & & DurationDuration

– When did it start?

– How long have you had this pain?

– When did you first notice it?

– Is it intermittent or continuous?

– How long does each episode last?

– Does the symptom vary with time of day?

– Have you ever experienced this before?

- Associations with specific events

– What places or events affect the symptom?

– Work vs. home

– Leisure activities

– Diet

– Emotions

– Heat, dust, altitude

Environment Environment

– How is the symptom interfering with the

patient’s daily functioning?

– If the patient has pain, how bad is the pain

on a scale of one to ten?

EnvironmentEnvironment

PatientPatient ’’ss IInterviewnterview

Past Medical History

– General state of health

– Chronic medical problems

– Hospitalizations

– Surgical history

– History of trauma

– Childhood illnesses

– Gynecologic history

– Health maintenance

• Childhood illnesses

• Adult illnesses

• Medical conditions

• Surgeries

• Obstetric/gynecologic

• Psychiatric

Past Medical HistoryPast Medical History

Eliciting the Past Medical History

– How would you describe your health?

– Are you having any other problems with your health?

– Do you have any other medical problems?

– Are you treated for any other medicalconditions?

You may learn more about this with medications!


Medical Problems

Chronic problems like:

• Diabetes mellitus

• Hypertension

• Chronic back pain

• Depression

• Coronary artery disease or MI

• Congestive heart failure


Medical Problems

– You can’t always accept the patient’s

diagnosis, use records to confirm.

– Are any of these problems active?

Childhood Illnesses

– Birth defects, ex., undescended testicle

– Attention deficit

– Drug use

– Anorexia

– Athlete

– Meningitis

– For Pediatrics information about the birth

is important

Hospitalizations

When?

Where?

Why?

For how long?


• What part of the body?

• Why?

• When?

• Where?

• Any complications?

• Reactions to anesthesia?

Past Surgical HistoryPast Surgical History

Trauma

What part of the body?

How injured?

Where hospitalized?

Reproductive History

– Menstruation

• Start

• Length and frequency

Pregnancies

• G = Gravida=pregnancies

• P = Para = Live births

Birth Control

Past Surgical History Past Surgical History –– cont.cont.

� Health Maintenance

� Immunizations

� Screening Tests

� Medications

� Medicine name

� Purpose

� Dose

� Route

� Frequency

� Side effects

� Taking as prescribed?

� Cost issues

MedicationsMedications

Don’t forget!

– Over the counter drugs (OCD)

– Vitamins

– Nutritional supplements

– Any borrowed medications

Medications Medications -- continuedcontinued

e.g penicilllin rash

Medications

- What is the reaction?

Other substances, if severe reaction

– Ex. Peanut or bee sting allergy

Known allergies Known allergies and resulting symptomsand resulting symptoms

• personal status

• occupation

• education

• home conditions

• interests

Social HistorySocial History

Genetic diseases

– Sickle cell anaemia, cystic fibrosis

Familial diseases

– Type 2 diabetes, breast cancer

Psychiatric diseases

– Heritable

– Affect patient’s psychosocial environment

Contagious or Toxic

– Lead poisoning, influenza

Family HistoryFamily HistoryMajor illnesses in the immediate family Major illnesses in the immediate family

(parents, grandparents, siblings) (parents, grandparents, siblings)

• HPI: Mary Smith was seen in my clinic today. She presents with a right breast lump which she noticed 2 weeks ago. The lump is quite firm. She denies weight loss or nipple discharge. ROS: She has noticed some swollen lymph nodes in her neck and axillary regions. Other systems are negative. PMHx: Her only hospitalizations were for the births of her 2 children over 20 years ago. SHx:She does not smoke or drink. FHx: Her mother had breast cancer and a mastectomy.

• PE: Mary is healthy appearing. Her eyes clear. Oropharayngeal membranes are pink and moist. Neck has good range of motion with no lymphadenopathy. Heart has a regular rate and rhythm and lungs are clear to auscultation. Abdomen is soft and non-tender. Breast exam revealed normal shape with no skin discoloration. A solid mass was identified in the right breast with some swelling of the axillary lymph nodes. She is alert and oriented x 3 and neurologically grossly intact.

• Labs and x-ray: Mammogram reveals a 2 cm mass in the right breast. She also has a small cyst in her left breast but no clear lymph node involvement.

• Impression: Otherwise healthy 46-year-old woman with right breast lump and axillary lymph node swelling. Plan: Mary and her husband were at my office for about 45 minutes and I spent 30 minutes talking to them about her prognosis and risks and benefits of surgery. She agrees to breast biopsy with sentinel node biopsy on Tuesday.

Sample Note Combining Time and ExamSample Note Combining Time and Exam

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