The Practice and Art of Medical History Taking

Question 1

can already be made from a good clinical history 80% of the time

Answer 1

Diagnosis

Question 2

First step in establishing patient rapport and building a good doctor-patient relationship

Answer 2

Diagnosis

Question 3

Doctor as __________

Answer 3

detective

Question 4

 Patients report the story of an illness as they have lived and remembered it

Answer 4

History

Question 5

are a universal human experience, but often have unique personal meaning

Answer 5

Symptoms

Question 6

Varies with age, socioeconomic status, culture and experiences

Answer 6

History

Question 7

Fact-finding, investigation about the disease

Answer 7

History-taking

Question 8

Observation of patient’s behavior and what the illness means to them

Answer 8

History-taking

Question 9

A skill and an art

Answer 9

History-taking

Question 10

Requirements of History-taking

Answer 10

ability to listen, ask common- sense questions and good intentions

Question 11

are true statements?

Answer 11

Facts

Question 12

consists of facts arranged in a useful manner

Answer 12

Information

Question 13

A history is not simply a collection of facts… The facts must be placed in a form that makes them informative.

Answer 13

order of facts is information (chronology matters)

Question 14

is the explanation the clinician brings to the symptoms, leads to diagnosis and management plan.

Answer 14

Disease

Question 15

is how the patient experiences the symptoms, shaped by previous experiences, how symptoms affect daily living, culture, age, and expectations about medical care

Answer 15

Illness

Question 16

without a patient and doctor’s relationship

Answer 16

there is no identification of illness

Question 17

Structure and Elements of the Health History



Answer 17

l General Data
l Chief Complaint
l History of Present Illness (HPI) l Review of Systems (ROS) l Past Medical History
l Family History
l Personal and Social History

Question 18

General Data

Answer 18

l Date and time of examination

l Identifying data: Name, age, sex, ethnicity, civil
status, religion, address

l Source of history and reliability

l Source of referral

Question 19

l Main reason the patient

Answer 19

Chief Complaint

Question 20

Usually a single symptom, but may be more

Answer 20

Chief Complaint

Question 21

Recorded in patient’s own words

Answer 21

Chief Complaint

Question 22

Be careful about recording a diagnosis in this area

Answer 22

Chief Complaint

Question 23

Not necessarily the first problem mentioned by patient

Answer 23

Chief Complaint

Question 24

 Clear, chronological narrative account of present problem (chief complaint)


Answer 24

History of Present Illness (HPI)

Question 25

order of what happened always written in a paragraph

Answer 25

History of Present Illness (HPI)

Question 26

THE SEVEN ATTRIBUTES OF A SYMPTOM

Answer 26

1. Location. Where is it? Does it radiate? 2. Quality. What is it like? 3. Quantity or severity. How bad is it? (For pain, ask for a rating on a scale of 1 to 10.) 4. Timing. When did (does) it start? How long did (does) it last? How often did (does) it come? 5. Setting in which it occurs. Include environmental factors, personal activities, emotional reactions, or other circumstances that may have contributed to the illness. 6. Remitting or exacerbating factors. Does anything make it better or worse? 7. Associated manifestations. Have you noticed anything else that accompanies it?

Question 27

Where is it? Does it radiate?

Answer 27

Location

Question 28

What is it like?

Answer 28

Quality

Question 29

How bad is it? (For pain, ask for a rating on a scale of | 1 to 10.)

Answer 29

Quantity or severity

Question 30

``` When did (does) it start? How long did (does) it last? How often did (does) it come? ```

Answer 30

Timing.

Question 31

Include environmental factors, personal activities, emotional reactions, or other circumstances that may have contributed to the illness.

Answer 31

Setting in which it occurs.

Question 32

Does anything make it better or worse?

Answer 32

Remitting or exacerbating factors

Question 33

Have you noticed anything else that | accompanies it?

Answer 33

Associated manifestations.

Question 34

For each symptom, remember :OPQRST

Answer 34

ONSET OF DIAGNOSIS PRECIPITATING AND PALLIATING FACTORS QUALITY, QUANTITY, SEVERITY REGION, RADIATION (LOCATION) SYMPTOMS ASSOCITED TIMING

Question 35

Detailed PROGRESSION or REGRESSION of symptoms very important!

Answer 35

HPI

Question 36

Include prior investigation, confinements, treatments if any for same complaint

Answer 36

HPI

Question 37

Sequential presentation

Answer 37

Relay story in days before admission l Narrate in detail

Question 38

Avoid medical terminology

Answer 38

HPI

Question 39

Must be written or presented in CONCISE, | grammatically-correct language

Answer 39

HPI

Question 40

Ability to discern what is essential and important data will come as you learn more about the pathophysiology of disease

Answer 40

HPI

Question 41

l Ask about symptoms in the other major body systems NOT mentioned in HPI

Answer 41

Review of Systems (ROS)

Question 42

Purpose:

Answer 42

Identify problems the patient has not mentioned so that they are not missed l Identify symptoms of other diseases l Identify symptoms of other diseases the patient may not know about l Identify symptoms which may be risk factors for present illness (ex. DM for CAD)

Question 43

If symptom appears to be related to Chief Complaint, move to?

Answer 43

HPI

Question 44

symptoms that are not connected to CC then write it under?

Answer 44

ROS

Question 45

Include pertinent POSITIVES and | NEGATIVES

Answer 45

ROS

Question 46

May be done during physical examination

Answer 46

ROS

Question 47

 Present known medical problems (HPN, DM, asthma, PTB etc). Note when diagnosed, meds if any, regular check-up. Current medications (including nontraditional: herbal meds, vitamins) with doses l Previous illness/confinement/surgery/blood transfusions l Allergies l Immunizations

Answer 47

Past Medical | history

Question 48

l Diseases among first or second degree relatives of the patient, listed according to disease, include age at onset and if cause of death

Answer 48

Family History

Question 49

Review following conditions: HPN, Heart Disease, DM, cancer, thyroid disease, seizure disorders, psychiatric disorders

Answer 49

Family History

Question 50

l If considering infectious disease, may inquire if other family members also have symptoms

Answer 50

Family History

Question 51

smoking (in pack years, attempts to quit), alcohol intake l illicit drug use (What? How much? When last used?) l work/occupation, diet and exercise, water supply and living conditions if necessary l sexual preference and activity l OB-Gyne History: if appropriate (obstetrical score, menarche/menopause)

Answer 51

Personal and Social History