History taking and General examination

So before taking you to the art of history taking, there are few things that you should know.

1. What to ask?
2. How to ask?
3. How to interpret?

The 2nd and 3rd step is easy if you are clear with the 1st step. Students often forget the points that should be asked in history taking.

So our main focus will be on this only – What to ask?

So let’s start –

So the name of the patient is Ana. 

We should start by taking the particulars of the patient. But before that make sure that the patient is oriented to time and place. If not then ask the attendant. 

This is different in different countries but it generally covers the following points –

1. Name
2. Age
3. Sex
4. Address
5. Occupation
6. Patient registration number

All these have some significance. Never ask something which is not required and never miss anything which is required.

After this let’s start the real game.

The first thing you are going to ask for is chief complaints or Presenting complaints. This is the complaint for which patient comes to you.

Ask the patient an open question such as ‘What’s the problem?’ or ‘What made you come to the doctor?’ And the patient should tell you the complaints and the time since they appear. In your notes, write them in the language of the patient in chronological order i.e. write first the one that is the oldest.

Let’s take an example – 

The history I am showing is from a real patient that I took myself in my 4th semester.

Presenting complains –

Breathlessness x 2days

Full body ache x 2days

Before moving forward I will tell you some things which I learned in postings and didn’t find in any books.

If you see the patient in I.P.D (Inpatient department), ask them how they came to the hospital – Emergency, O.P.D or referred from another hospital. If they came from another hospital, you should have to start the case by writing – Known case of _____.

If they have some precondition and the reason they came is a clear complication, you need to write – Known case of _____.

In this example, the patient came into the emergency room at 10:00 P.M.

After the Presenting complaints – you should have a differential diagnosis in your mind.

Now Let’s go further,

After noting the Presenting complaints, you need to ask a history of each presenting complaint.

Generally for each complaint – the following questions are asked –

• The exact nature of the symptom
• The onset:
      The date it began
      How it began (e.g. suddenly, gradually—over how long?)
      If long-standing, why is the patient seeking help now
• Periodicity and frequency:
     Is the symptom constant or intermittent?
     How long does it last each time?
     What is the exact manner in which it comes and goes?
• Change over time:
      Is it improving or deteriorating?
• Exacerbating factors:
      What makes the symptom worse?
• Relieving factors:
      What makes the symptom better?
• Associated symptoms.

The questions to ask about the characteristics of pain can be remembered with the mnemonic ‘SOCRATES’:
• S: Site (where is the pain worse? Ask the patient to point to the site
with one finger)
• O: Onset (how did it come on? Over how long?)
• C: Character (i.e. ‘dull’, ‘aching’, ‘stabbing’, ‘burning’, etc.)
• R: Radiation (does the pain shift or spread to elsewhere?)
• A: Associated symptoms (e.g. nausea, dyspepsia, shortness of
breath)
• T: Timing (duration, course, pattern)
• E: Exacerbating and relieving factors
• S: Severity 

If the symptom is long-standing, ask why the patient is seeking help now. Has anything changed? It is often useful to ask when the patient was last well.

After this – You should have a provisional diagnosis.

The next step is missed by a lot of students and it is very important – Negative history or Systemic inquiry. Some people take it in the last but I like to take it after the HOPI.

The questions asked will depend on the discussion that has gone before. Here are some things that you can ask –

General symptoms
• Change in appetite (loss or gain).
• Fever.
• Lethargy.
• Malaise.
Respiratory symptoms
• Cough.
• Sputum.
• Haemoptysis.
• Shortness of breath.
• Wheeze.
• Chest pain.
Cardiovascular symptoms
• Shortness of breath on exertion.
• Paroxysmal nocturnal dyspnoea.
• Chest pain.
• Palpitations.
• Ankle swelling.
• Orthopnoea.
• Claudication.
Gastrointestinal symptoms
• Weight loss or gain.
• Abdominal pain.
• Indigestion.
• Dysphagia.
• Odynophagia.
• Nausea.
• Vomiting.
• Change in bowel habits, diarrhea, constipation.
• PR blood loss.
Genitourinary symptoms
• Urinary frequency.
• Polyuria.
• Dysuria.
• Haematuria.
• Nocturia.

Neurological symptoms
• Headaches.
• Dizziness.
• Tingling.
• Weakness.
• Tremor.
• Fits, faints, ‘funny turns’.
• Black-outs.
• Sphincter disturbance.
Endocrine symptoms
• Heat or cold intolerance.
• Neck swelling (thyroid).
• Menstrual disturbance.
• Erectile dysfunction.
• Increased thirst.
• Sweating, flushing.
• Hirsutism.
• Muscle weakness.
Locomotor symptoms
• Aches, pains.
• Stiffness.
• Swelling.
Skin symptoms
• Lumps/bumps.
• Ulcers.
• Rashes.
• Other lesions (e.g. skin color or texture change).
• Itch.

No need to ask all these questions – Your patient will get fed up. Ask only the relevant ones.

Next, ask for Past Medical History –

For each condition, ask:
• When was it diagnosed?
• How was it diagnosed?
• How has it been treated?

Ask specifically about:
• Diabetes
• Rheumatic fever
• Jaundice
• Hypercholesterolaemia
• Hypertension
• Angina
• Myocardial infarction
• Stroke or TIA
• Asthma
• TB
• Epilepsy
• Anaesthetic problems
• Blood transfusions.

Don’t take anything for granted!

Then take the Drug History –

You should list all the medications the patient is taking, including the
dose, duration, and frequency of each prescription along with any significant side effects. Also, ask about Allergies and reactions.

After this, you need to take some specific Histories –

Family history

Social history

Personal History including – Alcohol, smoking, sleep pattern, bowel habits, etc.

The questions you ask in these should be based on your provisional Diagnosis.

Here is a video that will help you with the subject of history taking.