Basic concepts of history taking
Dr. Made Ratna Saraswati, SpPD Tuesday, 12 Oct 2010
References
Bickley LS, Szilagyi PG, 2009. Bates Guide to Physical Examination and History Taking, 10th edition. Lippincot William and Wilkins, Philadelphia.
Lloyd M & Bor R, 2004. Communication Skills for Medicine. Churcill Livingstone, New York
Patient - Doctor
A patient brings to doctor their problems, usually in the form of symptoms or complain The doctors role is to gain as accurate as possible, a picture of the patients problem
Developing a management plan for a patient
Establish a relationship with a patient
Gather information: History Physical examination Investigation
Make a diagnosis if possible Explain and discuss this with the patient
Formulate a management plan
Lloyd M & Bor R, 2004. Communication Skills for Medicine. Churcill Livingstone,
Rene Laennec (French physician)
Listen to the patient. They are giving you the diagnosis
9%
8%
83%
Diagnosis changed after investigation Diagnosis changed after physical examination
Fig. Relative contribution of history, physical examination, and investigations to final diagnosis
Determining the scope of your assessment
How much should I do?
Should my assessment be comprehensive or focused?
Comprehensive assessment
Focused assessment
Bickley LS, Szilagyi PG, 2009. Bates Guide to Physical Examination and History Taking, 10th edition. Lippincot William and Wilkins, Philadelphia.
Comprehensive assessment Is appropriate for a new patient in the office of hospital Provides fundamental and personalized knowledge about the patient Strengthens the clinician-patient relationship Helps identify or rule out physical causes related to patient concerns Provides baselines for future assessment Creates platform for health promotion through education and counseling Develops proficiency in the essential skills of physical examination
Focused assessment
Bickley LS, Szilagyi PG, 2009. Bates Guide to Physical Examination and History Taking, 10th edition. Lippincot William and Wilkins, Philadelphia.
Comprehensive assessment Is appropriate for a new patient in the office of hospital Provides fundamental and personalized knowledge about the patient Strengthens the clinician-patient relationship Helps identify or rule out physical causes related to patient concerns Provides baselines for future assessment Creates platform for health promotion through education and counseling Develops proficiency in the essential skills of physical examination
Focused assessment Is appropriate for established patients, especially during routine or urgent care visits
Addresses focused concerns or symptoms
Assesses symptoms restricted to a specific body system Applies examination methods relevant to assessing the concern of problem as precisely and carefully as possible
Bickley LS, Szilagyi PG, 2009. Bates Guide to Physical Examination and History Taking, 10th edition. Lippincot William and Wilkins, Philadelphia.
Differences between subjective and objective data
Subjective data What the patient tells you Objective data What you detect during the examination
The history, from chief All physical examination finding complaint through review of systems
Bickley LS, Szilagyi PG, 2009. Bates Guide to Physical Examination and History Taking, 10th edition. Lippincot William and Wilkins, Philadelphia.
Differences between subjective and objective data
Subjective data What the patient tells you Objective data What you detect during the examination
The history, from chief All physical examination finding complaint through review of systems Example: Mrs. G is an older, overweight female, who is pleasant and cooperative, height 154cm, weight 62 kg, BMI 26.14, blood pressure 160/80, heart 96 and regular, respiratory rate 24, temperature 5oC 36 Bickley LS, Szilagyi PG, 2009. Bates Guide to Physical Examination and History Taking, 10th edition. Lippincot William and
Wilkins, Philadelphia.
Example: Mrs. G is a 54 years old hairdresser who reports pressure over her left chest, which goes into her left neck and arm.
The seven components of the Comprehensive Adult Health History
1. 2. 3. 4. 5. 6. 7.
Initial information: identifying data and source of the history Chief complaint (s) Present illness Past history Family history Personal and social history Review of the systems
1. Initial information
Date and time of history: the date is always important, be sure to document the time you evaluate the patient especially in urgent, emergent, or hospital setting Identifying data: age, gender, occupation, marital status Source of history: usually the patient, but can be a family member or friend, letter of referral, or the medical record If appropriate, establish source of referral because a written report may be needed. Reliability: Varies according to the patients memory, trust, and mood
2. Chief complaint (s)
The one or more symptoms or concerns causing the patient to seek care Quote the patients own words
3. Present illness
Each principal symptom should be well characterized with seven attributes
1. 2.
3.
4. 5. 6. 7.
Location Quality Quantity or severity Timing, including onset, duration, and frequency The setting in which it occurs Factors that have aggravated or relieved the symptom Associated manifestation
May include
(which are frequently pertinent to the present illness):
Medications
Allergies Habits
of smoking and drug
Alcohol
4. Past history
List List
1.
childhood illnesses adult illnesses
2.
3. 4.
Medical Surgical Obstetric/gynecologic Psychiatric
Includes
health maintenance practices
5. Family history
Outlines or diagrams age and health, or age and cause of death, of siblings, parents, and grandparents, children and grandchildren. Specific illnesses in family History of cancer Genetically transmitted disease
6. Personal and social history
Captured the patient personality, interest, sources of support, coping style, strength, and fears. Occupation Last year of schooling/education Home situation and significant others Source of stress Important life experiences Leisure activities Religious affiliation and spiritual beliefs Activities of daily living (ADL) Lifestyle habits that promote health of create risk Describes educational level, family of origin, current household, personal interest, and lifestyle
7. Review of the systems
Documents presence or absence of common symptoms related to each major body system
Writing up the patients notes
The notes should be written clearly and concisely under the same headings used for taking the patient history
Modifying the history taking sequence
It is important to learn and practice the history taking sequence. By taking a history in structure, you are less likely to miss important information. However you will need to modify in some situation.
Some practical hints
Take every opportunity you are given to interview Be prepared to spend time with patient Skill:
Establish rapport Listen actively Ask mainly open question Pick up and respond to verbal and non-verbal cues Summarize and check for accuracy
Make an aide memoire sequence Take note
