Hi
History taking is an art and one of the first learning thing in the medical field. Once a medical student enters into his second year of study, the hospital or clinical duties get started and students learn this art of history taking. Proper and accurate history taking is very important , because half of the diagnosis can be made if you take a proper history.
History taking is an art and needs a little bit of practice. History taking start with the following .
1. Name of the patient: Name is very important to document because if you talk with your patient by asking his name, it gives a sense of confidence to the patient and a good understanding between the patient and the doctor.
2. Age: It is also important to document age of the patient as certain diseases are common in particular age groups. For example certain diseases are common in paediatric age group and some of the diseases are common in older age group.
3. Sex: Some diseases are common in males and some diseases are particularly common in females.For example connective tissue disorders like SLE are more common in females.
4. Address: It is important to note address of the patient as certain diseases may be common in a particular geographical area or locality.For example Lymphatic filariasis is common in eastern part of India.
5. Occupation: Occupation of the patient is important to document because certain diseases are related with particular occupation e.g. Silicosis, Asbestosis etc.
6. Religion 7. Marital status
After noting these points , a student usually asks the Chief complaints.
Following points should be noted.
1. Chief complaint should be noted in patient language as far as possible.
2. If there are two or more chief complaints, note them in chronological order.e.g. If a patient complaints cough wit expectoration for 2-3 days , breathlessness for 5-6 days, note it as under
- Breathlessness for 5-6 days
- Cough with expectoration for 2-3 days
After noting the chief complaints, come the History of present illness
History of present illness: This is the most important part of history taking . History of present illness starts with explaining the chief complaints in detail. Start like this
History dates back to ........ when the patient started developing ....... Then note the progression of the symptoms with time.Also note whether there is improvement in the symptoms with time or static or there is worsening of the symptoms.
It is also important to note the aggravating or reliving factors at this stage.
Note: First stick to Chief complaint in HOPI and explore at fully, then proceed to next system and ask some questions related to other systems also to rule out other problems. e.g. If the patient comes with chief complaint of pain abdomen for last two weeks, first ask about pain abdomen, then ask questions related to abdominal diseases like jaundice, loss of appetite, urinary or bowel disturbance. After this, proceed to other systems say Respiratory, CVS and neurology.
It is important to keep in mind that medical terminology should be avoided while taking history.
It is important to keep differential diagnosis in mind while elaborating and taking history of present illness.
These questions related to other systems may not be closely related to chief complaint, but these are a part of general screening for the whole body as patient might be having some other associated problems and it will be helpful to get a clue regarding these diseases e.g If the chief complaint of the patient is respiratory difficulty and patient may tell you that there is history of weight gain, loss of hairs, constipation etc, you may think of Hypothyroidism.
History of past illness: after the history of present illness, move on to write history of pass illness. Ask about history of Diabetes mellitus, Hypertension, Coronary artery disease, Bronchial asthma, tuberculosis in the past.
Try to ask about how the patient came to know about any particular disease if a particular patient gives history of any illness in the past e.g. if patient says that he is diabetic for last 10 years, ask how he came to know that he/she is diabetic and which medication he is taking for that illness, whether it is well controlled or uncontrolled.
Also ask history of any previous hospitalization and history of any surgical intervention in the past.
Personal History : In this part of history taking, ask whether patient is married or not, how many children he/she have, ask about dietary habits- Vegetarian or non-vegetarian, is there any history of smoking or alcohol abuse or any other illicit drug abuse. If there is history of smoking present, calculate smoking index and pack years.
If patient gives history of alcohol consumption, ask about the type of brand e.g. whisky or rum or Beer etc. as these contain different quantities of alcohol in grams and calculate the alcohol intake in terms of grams .
Significant alcohol intake: In males, 60-80 grams of alcohol intake for more than 10 years is significant and in females 40-60 grams of alcohol intake is considered significant.
Question: How to convert amount of alcohol taken into grams of alcohol?
Ans: 100 ml of beer contains 4-6% alcohol by volume
100 ml of Wine contains 10-12% alcohol by volume
100ml of rum contains around 35%
100 ml of Gin,Whisky , Vodka contains around 40% alcohol by volume
Also note the history of other substance abuse like opium addiction, sleeping pills, barbiturates, cocaine etc.
In females, ask about the history of menstruation that is, if there is any history of increased vaginal bleeding ,ask about the history of menopause, and any post menopausal bleed if any.
Family history: The medical students should also inquire about the similar complaints in the other family members . This is especially important in cases of infectious diseases like tuberculosis, influenza etc. It is also important in other diseases which run in families like Ataxia, DM, HT, Coronary artery disease.
Social history: It is important to note the social history of patient like educational status, financial status, environment at home whether living in well built house or some kaccha house.
Treatment history: The students should note the treatment taken for the current illness starting from the beginning and what treatment has been done, whether treatment given in form of capsules, tablets, intravenous drugs etc and history of hospitalization for the current illness and also note regarding the benefit , whether there is improvement or worsening of the symptoms after starting the treatment.
History taking is an art and one of the first learning thing in the medical field. Once a medical student enters into his second year of study, the hospital or clinical duties get started and students learn this art of history taking. Proper and accurate history taking is very important , because half of the diagnosis can be made if you take a proper history.
History taking is an art and needs a little bit of practice. History taking start with the following .
1. Name of the patient: Name is very important to document because if you talk with your patient by asking his name, it gives a sense of confidence to the patient and a good understanding between the patient and the doctor.
2. Age: It is also important to document age of the patient as certain diseases are common in particular age groups. For example certain diseases are common in paediatric age group and some of the diseases are common in older age group.
3. Sex: Some diseases are common in males and some diseases are particularly common in females.For example connective tissue disorders like SLE are more common in females.
4. Address: It is important to note address of the patient as certain diseases may be common in a particular geographical area or locality.For example Lymphatic filariasis is common in eastern part of India.
5. Occupation: Occupation of the patient is important to document because certain diseases are related with particular occupation e.g. Silicosis, Asbestosis etc.
6. Religion 7. Marital status
After noting these points , a student usually asks the Chief complaints.
Following points should be noted.
1. Chief complaint should be noted in patient language as far as possible.
2. If there are two or more chief complaints, note them in chronological order.e.g. If a patient complaints cough wit expectoration for 2-3 days , breathlessness for 5-6 days, note it as under
- Breathlessness for 5-6 days
- Cough with expectoration for 2-3 days
After noting the chief complaints, come the History of present illness
History of present illness: This is the most important part of history taking . History of present illness starts with explaining the chief complaints in detail. Start like this
History dates back to ........ when the patient started developing ....... Then note the progression of the symptoms with time.Also note whether there is improvement in the symptoms with time or static or there is worsening of the symptoms.
It is also important to note the aggravating or reliving factors at this stage.
Note: First stick to Chief complaint in HOPI and explore at fully, then proceed to next system and ask some questions related to other systems also to rule out other problems. e.g. If the patient comes with chief complaint of pain abdomen for last two weeks, first ask about pain abdomen, then ask questions related to abdominal diseases like jaundice, loss of appetite, urinary or bowel disturbance. After this, proceed to other systems say Respiratory, CVS and neurology.
It is important to keep in mind that medical terminology should be avoided while taking history.
It is important to keep differential diagnosis in mind while elaborating and taking history of present illness.
These questions related to other systems may not be closely related to chief complaint, but these are a part of general screening for the whole body as patient might be having some other associated problems and it will be helpful to get a clue regarding these diseases e.g If the chief complaint of the patient is respiratory difficulty and patient may tell you that there is history of weight gain, loss of hairs, constipation etc, you may think of Hypothyroidism.
History of past illness: after the history of present illness, move on to write history of pass illness. Ask about history of Diabetes mellitus, Hypertension, Coronary artery disease, Bronchial asthma, tuberculosis in the past.
Try to ask about how the patient came to know about any particular disease if a particular patient gives history of any illness in the past e.g. if patient says that he is diabetic for last 10 years, ask how he came to know that he/she is diabetic and which medication he is taking for that illness, whether it is well controlled or uncontrolled.
Also ask history of any previous hospitalization and history of any surgical intervention in the past.
Personal History : In this part of history taking, ask whether patient is married or not, how many children he/she have, ask about dietary habits- Vegetarian or non-vegetarian, is there any history of smoking or alcohol abuse or any other illicit drug abuse. If there is history of smoking present, calculate smoking index and pack years.
If patient gives history of alcohol consumption, ask about the type of brand e.g. whisky or rum or Beer etc. as these contain different quantities of alcohol in grams and calculate the alcohol intake in terms of grams .
Significant alcohol intake: In males, 60-80 grams of alcohol intake for more than 10 years is significant and in females 40-60 grams of alcohol intake is considered significant.
Question: How to convert amount of alcohol taken into grams of alcohol?
Ans: 100 ml of beer contains 4-6% alcohol by volume
100 ml of Wine contains 10-12% alcohol by volume
100ml of rum contains around 35%
100 ml of Gin,Whisky , Vodka contains around 40% alcohol by volume
Also note the history of other substance abuse like opium addiction, sleeping pills, barbiturates, cocaine etc.
In females, ask about the history of menstruation that is, if there is any history of increased vaginal bleeding ,ask about the history of menopause, and any post menopausal bleed if any.
Family history: The medical students should also inquire about the similar complaints in the other family members . This is especially important in cases of infectious diseases like tuberculosis, influenza etc. It is also important in other diseases which run in families like Ataxia, DM, HT, Coronary artery disease.
Social history: It is important to note the social history of patient like educational status, financial status, environment at home whether living in well built house or some kaccha house.
Treatment history: The students should note the treatment taken for the current illness starting from the beginning and what treatment has been done, whether treatment given in form of capsules, tablets, intravenous drugs etc and history of hospitalization for the current illness and also note regarding the benefit , whether there is improvement or worsening of the symptoms after starting the treatment.
