History taking

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Lecture for postgrad students in different courses of BSMMU

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HISTORY TAKING:

HISTORY TAKING Prof. Dr. AKM Mosharraf Hossain Professor & Chairman Dept of Respiratory Medicine Bangabandhu Sheikh Mujib Medical University

Topics:

Topics Introduction Chief complaint History of present illness Past medical history Systemic enquiry Family history Drug history Social history 2

What Is Medical History?:

What Is Medical History? The medical history or case history (also called epicrisis or anamnesis) is information gained by a physician by asking specific questions, either of the patient or of other people who know the person and can give suitable information (called heteroanamnesis ), with the aim of obtaining information useful in formulating a diagnosis and providing medical care to the patient. 3

Importance of History Taking:

Importance of History Taking “ Listen to your patient; he is telling you the diagnosis .” This was what the great physician William Osler taught his students in the late 19 th century. His words are still true today . Engel and Morgan called it “the most powerful and sensitive and most versatile instrument available to the physician” 4

Importance of History Taking:

Importance of History Taking Obtaining an accurate history is the critical first step in determining the etiology of a patient's problem. Studies conducted in the United States, India, and Brazil also reported that history-taking was responsible for 76%, 78.6%, and 77.8% of all diagnoses made, respectively. The history and physical examination alone contribute 73% to 94% of the diagnostic information, with costly testing and procedures contributing much less . 5

How to take a history?:

How to take a history? The sense of what constitutes important data will grow exponentially in future as you learn about the pathophysiology of disease You are already in possession of the tools that will enable you to obtain a good history. An ability to listen & ask common-sense questions that help define the nature of a particular problem. A vast & sophisticated fund of knowledge not needed to successfully interview a patient. 6

General Approach :

General Approach Introduce yourself. Let the patient sit in a friendly relaxed way . Keep confidentiality and respect patient privacy . Try to see things from patient point of view and understand mental status, anxiety, irritation or depression of the patient. Encourages patient to tell story in open-ended fashion; conveys sense that clinician wishes to hear and understand Invites patient to state the agenda; allows patient to use judgment about problems to emphasize; often is most efficient way to hear story 7

Taking the history & Recording :

Taking the history & Recording Always record personal details: Name, Age, Address, Sex, Ethnicity Occupation, Religion, Marital status. Date of examination 8

Complete History Taking:

Complete History Taking Chief complaint History of present illness Past medical history Systemic review Family history Drug history Social history Gyn / ob history. 9

CHIEF COMPLAINT:

CHIEF COMPLAINT

Chief Complaint:

Chief Complaint The main reason for visiting a physician Usually a single symptoms, occasionally more than one complaints eg : chest pain, palpitation, shortness of breath, ankle swelling etc The patient describe the problem in their own words. It should be recorded in pt’s own words. What brings you here? How can I help you? What seems to be the problem? 11

Chief Complaint:

Chief Complaint Short/ specific in one clear sentence communicating present/ major problem/ issue. As: Timing – fever for last two weeks or since Monday Recurrent –recurring episode of abdominal pain/cough Any major disease important e.g. DM, asthma, HT, pregnancy, IHD: Note : CC should be in patient’s language. 12

Duration: tips:

Duration: tips Exact duration. For how long you are ill. When you were completely normal. Is this complain for the first time or you have other episodes. 13

History of Present Illness:

History of Present Illness

History of Present Illness - Tips:

History of Present Illness - Tips E laborate the chief complaint in detail Ask relevant associated symptoms Have differential diagnosis in mind Lead the conversation & thoughts Decide & weight the importance of minor complaints Present problems with- time of onset/ mode of evolution/ any investigation, treatment & outcome/any associated +’ve or -’ve symptoms. 15

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Sequential presentation Always relay story in days before admission e.g. 1 week before the admission, the patient fell while gardening & cut his foot with a stone. Narrate in details – By that evening, the foot became swollen and patient was unable to walk. Next day patient attended hospital and they gave him some oral antibiotics. He doesn’t know the name. There is no effect on his condition and two days prior to admission, the foot continued to swell and started to discharge pus. There is high fever and rigors with nausea and vomiting. History of Presenting Complaint (HPC) 16

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History of Presenting Complaint (HPC) In details of symptomatic presentation If patient has more than one symptom, like chest pain, swollen legs and vomiting, take each symptom individually and follow it through fully mentioning significant negatives as well. E.g the pain was central crushing pain radiating to left jaw while mowing the lawn. It lasted for less than 5 minutes and was relieved by taking rest. He did never notice this pain before/no relation with food. He is a known smoker and diabetic. His father died of heart attack at the age of 45 yrs. 17

History of Present Illness - Tips:

History of Present Illness - Tips Avoid medical terminology & make use of a descriptive language that is familiar to the patient. Ask OPQRSTA for each symptom 18

PAIN (OPQRST):

PAIN (OPQRST) O nset of disease P osition/site Q uality, nature, character – burning sharp, stabbing, crushing; also explain depth of pain – superficial or deep . R elationship to anything or other bodily function/position. R adiation: where moved to R elieving or aggravating factors – any activities or position 19

PAIN (OPQRST):

PAIN (OPQRST) S everity – how it affects daily work/physical activities. Wakes him up at night, cannot sleep/do any work . T iming – mode of onset (abrupt or gradual), progression (continuous or intermittent – if intermittent ask frequency/ nature.) T reatment received or/and outcome. Are there any associated symptoms? . 20

Past Medical Illness:

Past Medical Illness

Past Medical /Surgical History:

Past Medical /Surgical History Start by asking the patient if they have any medical problems IHD/Heart Attack/DM/Asthma/HTN/RHD,TB/Jaundice/Fits :e.g. if diabetic- mention time of diagnosis/current medication/clinic check up Past surgical/operation history: e .g. time/place/ what type of operation. Note any blood transfusion / blood grouping. H/O dental extractions/circumcision & any exessive bleeding during these procedures. History of trauma/accidents: e .g. time/place/ and what type of accident Any minor operations or procedures including endoscopies, dental interventions, biopsies. 22

Drug History:

Drug History

Drug History:

Drug History Always use generic name or put trade name in brackets with dosage, timing & how long: example: Ranitidine 150 mg BD PO Note: do not forget to mention: OCT/Vitamins/Traditional /Herbal medicine & alternative medicine as cupping or cattery or acupuncture. Blod transfusion. 24

Drug History:

Drug History bd ( Bis die) - Twice daily (usually morning and night) tds ( ter die sumendus )/ tid ( ter in die) = Three times a day mainly 8 hourly qds (quarter die sumendus )/ qid (quarter in die) = four times daily mainly 6 hourly Mane/( om – omni mane) = morning Nocte /(on – omni nocte ) = night ac (ante cibum ) = before food pc (post cibum ) = after food po (per orum / os ) = by mouth stat – statim = immediately as initial dose Rx (recipe) = treat with 25

Family History:

Family History

Family History:

Family History Any familial disease/running in families e.g. breast cancer, IHD, DM, schizophrenia, Developmental delay, asthma, albinism. Infections running in families as TB, Leprosy. Cholera, typhoid in case of epidemics. 27

Social History:

Social History

Social History:

Social History Smoking history - amount, duration & type. A strong risk factor for IHD Alcohol history - amount, duration & type. Occupation, social & educational background, ADL, family social support & financial situation. Social class. Home conditions as: water supply, sanitation & pet animals / birds in house. 29

Social History: smoking:

Social History: smoking The most important cause of preventable diseases. Smoking history - amount, duration & type. Amount: pack year calculations. Duration: continuous or interrupted. Any trials of quitting & how many. Active or passive smoker. Type: packs, self-made, Cigars, Shesha , chewing etc. If he is willing to quit, but can not, help him by NRT, buberpion . 30

Social History: alcohol.:

Social History: alcohol. Whether drinking alcohol or not. If drinking know whether it is healthy or not. Healthy alcohol use: Men: 14 units/week, not > 4 units/session; Women: 7 units/week, not > 2 units/session. Possibility of addiction with its known health problems . Unhealthy alcohol use is associated with cardiomyopathy, CVA, Myopathies, liver cirrhosis & CPNS dysfunction. 31

Other Relevant History :

Other Relevant History Gyane /Obstetric history if female Gravida , para , abortions, SZ sections, antenatal care & screens as for Hep B & C. 32

Other Relevant History :

Other Relevant History Immunization- if child Note: Look for the child health card. Travel / sexual history if suspected STDs or infectious disease Note: If small child, obtain the history from the care giver. Make sure; talk to right care giver. If some one does not talk in your language, get an interpreter (neutral not family friend or member also familiar with both language). Ask simple & straight question but do not go for yes or no answer. 33

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System Review (SR) This is a guide not to miss anything Any significant finding should be moved to HPC or PMH depending upon where you think it belongs. Do not forget to ask associated symptoms of PC with the system involved When giving verbal reports, say no significant finding on systems review to show you did it. However when writing up patient notes, you should record the systems review so that the relieving doctors know what system you covered. 34

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System Review General Weakness Fatigue Anorexia Change of weight Fever/chills Night sweats Lumps 35

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System Review Cardiovascular Chest pain Paroxysmal Nocturnal Dyspnoea Orthopnoea Shortness of Breath(SOB) Cough/sputum ( pinkish/frank blood ) Swelling of ankle ( SOA) Palpitations Cyanosis 36

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System Review Gastrointestinal/Alimentary Appetite (anorexia/weight change) Diet Nausea/vomiting Regurgitation/heart burn/flatulence Difficulty in swallowing Abdominal pain/distension Change of bowel habit Haematemesis , melaena , haematochagia Jaundice 37

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System Review Respiratory System Cough ( productive/dry) Sputum ( colour , amount, smell) Haemoptysis Chest pain SOB/ Dyspnoea Tachypnoea Hoarseness Wheezing 38

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System Review Urinary System Frequency Dysuria Urgency/ strangury Hesitancy Terminal dribbling Nocturia Back/loin pain Incontinence Character of urine : color / amount (polyuria) & timing Fever 39

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System Review Nervous System Visual/Smell/Taste/Hearing/Speech problem Headache Fits/Faints/Black outs/loss of consciousness Muscle weakness/numbness/paralysis Abnormal sensation Tremor Change of behaviour or psyche . 40

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System Review Genital system Pain/ discomfort/ itching Discharge Unusual bleeding Sexual history Menstrual history – menarche/ LMP/ duration & amount of cycle/ Contraception Obstetric history – Para/ gravida /abortion 41

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System Review Musculoskeletal System Pain – muscle, bone, joint Swelling Weakness/movement Deformities Gait 42

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SOAP S ubjective: how patient feels/thinks about him. How does he look. Includes PC and general appearance/condition of patient O bjective – relevant points of patient complaints/vital sings, physical examination/daily weight , fluid balance , diet/laboratory investigation and interpretation P lan – about management, treatment, further investigation, follow up and rehabilitation A ssessment – address each active problem after making a problem list. Make differential diagnosis . 43

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