History Taking

Presenting the patient

• Acronyms used in the Patient’s notes
  • Chief complaint: CC
  • History of presenting illness: HPI
  • Review of systems: ROS
  • Past medical history: PMHx
  • Past surgical history: PSHx
  • Social history: SHx
  • Family history: FHx
  • Medications: Meds
• How to present your history
  • Introduction: Patient name, age and occupation
  • Main Presenting complaints: From open and closed questions
  • Other symptoms from screening
  • The patient’s Ideas, Concerns and Expectations
  • Relevant negatives from risk factor questions
  • Top differentials
  • Other differentials
  • Possible causes from risk factors
  • Complications from your top differentials that you would like to exclude

Presenting Complaint

• Introducing the patient (Biodata, Demographics etc.)
  • Includes:
    • Full names,
    • Age,
    • Sex,
    • Admit duration – 2nd date of admission, 1 week of admission etc.
    • Occupation – as a risk factor or to provide decision for management
    • Location – In case of outbreaks (Remember to note down the school students attend, it might have implications for the diagnosis)
    • Religion? – Depends on the context (risk factors, diet, therapies)
    • Marital status? – Depends on the context
    • Chronic illnesses
      • Duration of illnesses
      • Medications the patient uses to treat the illness
      • Compliance to medication
      • Reasons for non-compliance
      • Any side effects
      • Clinic
      • Compliance to Clinic attendance
  • Always include chronic diseases in the patient’s introduction
    • Treat each condition as it own: Condition 1 + duration + meds and compliance; Condition 2 + duration + meds and compliance
    • Of course the patient won’t remember the exact date they were diagnosed with the chronic condition (Patient’s do not hold anniversaries for their conditions, hence the need to use prompt’s to get a rough estimate of the duration)
    • State the drug used, dose, and frequency for each disease. Check the documentation and use generic names.
    • Errors in prescription? Correct the dosage if needed and know the side effects of the drugs (might manifest as the chief complaint!)
• Chief Complaint (CC)
  • Brief statement of the reason for the encounter.
  • BE VERY SPECIFIC!
  • Should guide the rest of the interview; with overall history conducted to tell story of patient’s primary problem.
  • WATCH OUT FOR ADDITIONAL CONCERNS EXPRESSED LATER THAT MAY BE MORE IMPORTANT THAN THE INITIAL CC. Then add them.
  • Document the later issue if more important (as the CC).
  • GOOD TO DRAW DIAGRAMS
• History of Present Illness (HPI)
  • FULL description
  • “Tell me more about ‘x’.”
    • Location — where is the pain? can you point to where it’s coming from? does it go anywhere from there?
    • Quality — what does it feel like? does it remind you of anything?
    • Severity — how bad does it get? scale of 1-10, right now? does it limit your activity?
    • Onset/duration — when did you notice it? when was the last time you felt normal? how long does it last?
    • Course — is it constant, or on-and-off? how often? is it getting better or worse with time?
    • Triggers/modifiers — Can you think of anything that triggers this? Is there anything that makes it better or worse? Have you tried any home treatments?
    • Context — Does it happen only at particular times/situations? Does anyone around you have this?
    • Association — Have you noticed any other symptoms along with this? (Guide with specific related symptoms, e.g. cough ~ dyspnea or fever).
  • DON’T INTERRUPT!
  • Where the differentials are made. Go system by system, listen to the story to get the flow then organize your work.
  • Avoid making it a Layman’s History
    • Identify which parts of the patient’s stories are relevant
    • Ignore investigations or treatments until the very end (Finish by asking whether they have been treated before)
  • Patient has a chronic condition? Ask about:
    • When it was diagnosed (How long they have been living with the condition)
    • Medications they are taking
    • Compliance and reasons for non-compliance if applicable
    • Whether they attend or have defaulted on clinics
  • Organizing the HPI
    • Start with the symptoms (describe them as above)
    • Follow with any risk factors or exacerbating factors
    • Finally ask about the potential complications the patient might have in any relevant systems (for chronic or multisystem conditions, cover all the systems involved in the HPI)

Review of Systems

• Review of Systems (ROS)
  • Use  yes/no questions here (unlike rest of interview)
    • specific
  • List of symptoms (present/absent) in other body systems; once the systems involved in the c/o have been exhausted
  • the level of detail for each system will depend on the patient’s primary problem.
  • e.g. Cough? Then, ENT, allergies/immune, pulmonary and cardiovascular review should be heavily emphasized; whereas MSK and GU are tangential and can briefly discuss.
  • may be performed while performing PE of the corresponding systems, but should be done sparingly
  • THERE IS NO CAUSE TO PICK ANAEMIA AND JAUNDICE AS INCIDENTALS. Reduce “Query cause”
• ROS: Constitutional
  • Do you have fevers or chills?
  • Noticed any unexpected weight gain/loss?
  • Do you feel unusually tired?
  • Have you had any sweats at night?
• ROS: E/N/T
  • Have you had any difficulty hearing in either ear?
  • Do you have pain in either ear?
  • Do you have ringing in your ears or hear other unusual sounds?
  • Have you had a runny nose or nasal congestion?
  • Have you had a sore throat?
  • Have you noticed any changes in your voice?
  • Do you have difficulty swallowing?
• ROS: Cardiovascular
  • Have you had any chest pain?
  • Do you feel your heart racing, pounding, or beating unusually fast?
  • Do you get short of breath easily? If so, how far can you walk before becoming short of breath?
  • Do you get short of breath if you lie flat?
  • Do you have pain in the back of your legs, calves or thighs while walking?
  • Have you had any swelling in your legs or ankles?
  • Do you have varicose veins?
• ROS: Respiratory
  • Have you had a cough?
  • If so, are you coughing anything up?
  • Are you coughing up blood? If so, how much?
  • Have you had shortness of breath?
  • Do you have any wheezing?
• ROS: Gastrointestinal
  • Have you had nausea or vomiting?
  • If so, are you throwing up blood?
  • Have you had constipation or diarrhea?
  • Have you had heartburn or stomach acid come up in your throat?
  • Have you had belly pain?
  • Do you have blood in your stool, or thick, black, sticky stools?
  • Have you had any pain with bowel movements?
  • Have you had yellow eyes or skin?
• ROS: GU (minus reproductive)
  • Have you had to urinate more often?
  • Does it hurt when you urinate?
  • Do you have blood in the urine?
  • Have you had trouble controlling your urine?
  • Have you noticed bumps or sores in your genital area?
• ROS: GU (male reproductive)
  • Do you wake up to urinate at night?
  • If so, how many times?
  • Have you noticed that your urine stream is getting weaker?
  • Do you have trouble getting or maintaining an erection?
  • Have you had discharge from your penis?
  • Have you had pain in the penis, scrotum, or testicles?
• ROS: GU (female reproductive)
  • Have you had itching or pain in the vaginal area?
  • Have you had vaginal discharge?
  • What age did you start having periods?
  • When was your last menstrual period?
  • How often are your periods? How many days do they last?
  • Have you had irregular periods or bleeding between periods?
• ROS: MSK
  • Do you have any weakness in your legs or arms?
  • Have you had pain or stiffness in your muscles or joints?
  • Have you had swelling in your joints?
  • Do you have back or neck pain? Where?
  • Do you have muscle cramps?
• ROS: Eyes
  • Do you have any vision problems?
  • Do you have pain in your eyes?
  • Are your eyes more sensitive to light?
  • Have you had any redness or discharge?
• ROS: Neurologic
  • Do you have headaches?
  • Do you have dizziness? What does it feel like?
  • Have you passed out?
  • Have you injured your head, like in a fall?
  • Do you have numbness or tingling in any part of your body?
  • Have you had problems with your memory?
  • Do you have difficulty with your speech?
• ROS: Skin + Breast
  • Have you had any rashes?
  • Have you had unusual skin itching?
  • Have you had itchy bumps (“hives”) on your skin?
  • Have you had changes in your hair or nails?
  • Have you noticed skin lumps or changes in moles?
  • Have you noticed lumps or pain in either breast?
  • Have you had discharge from the nipples?
  • Have you noticed skin changes in the breasts?
• ROS: Psychiatric
  • Have you had difficulty falling or staying asleep at night?
  • Have you noticed a change in your mood recently?
  • Has anyone noticed any changes in your thinking or behavior?
  • Have you been under unusual stress lately?
• ROS: Endocrine (+ female only)
  • Do you feel warm or cold when everyone else in the room appears comfortable?
  • Have you been more thirsty than usual, or do you urinate more than usual?
  • Have you been through menopause?
  • Have you had bleeding since you stopped having periods?
• ROS: Hematologic/Lymphatic
  • Have you noticed lumps or swollen glands anywhere on the body?
  • Do you bruise or bleed more easily than usual?
  • Have you noticed any bleeding from your gums, or frequent nosebleeds?
• ROS: Allergic/Immunologic
  • Do you have problems with seasonal or year-round allergies?
  • Do you seem to get frequent, serious infections?

Past History

• Past Medical History (PMHx)
  • “Before we continue, I would like to get a little background about you so that I can understand your current problem better.”
  • Past or chronic illnesses, injuries,
  • CURED DISEASES (Diabetes and HTN cannot be part of PMHx. Exhaust them in the introduction to the patient or HPI)
  • Allergies
  • Exposure history
  • Surgeries
  • Developmental history (for peds)
  • OB/GYN history (if appropriate)
  • (comes after CC/HPI=>ROS=>PMH)
• Medications & Allergies
  • Rx, OTC, vitamins, supplements
  • Allergic reactions to medications/medical agents (hi, latex)
  • Significant environmental or food allergies
  • Taking any discontinued medications?
• Family History
  • Just those that may affect the patient (ie, relevant)
  • Focus on 1st-degree relatives; expanding only if genetic disorders are suspected within the family.
  • Open-ended questioning.
  • Can draw a pedigree if there is genetic predisposition to the a disease (check context!)
  • DO NOT ASK HOW MANY BEDROOMS/ WINDOWS A DIABETIC PATIENT HAS IN THEIR HOUSE! (Again, check the context!)
• Dietary History
  • 24 hour dietary recall
• What to do after the patient interview
  1. Summarize the history with the patient
  2. Discuss you concerns and what you will look for on PE and what your plan of action will be
  3. Ask if the patient has ICE (Idea, concerns, expectations)

OBGYN History

• OBGYN Hx
  • Obtain in all women of reproductive age; adjust level of detail accordingly (i.e. more if asking for prenatal care, c/o STI, sexual abuse, or condition that may affect reproductive organs).
  • Obtain permission before probing sensitive matters; avoid leading/judgmental questions.
  • AGE, MENARCHE, LMP, GTPAL status
• OBGYN Hx: Menstrual Hx
  • When was your LMP?
  • How old were you when you had your first period?
  • Are your cycles regular?
  • How many days does your period last?
  • How many pads or tampons do you use on the heaviest day of your period?
  • Do you have abdominal cramps/pain before or during your period?
• OBGYN Hx: Sexual Hx/STIs
  • Are you sexually active?
  • If so, with men, women, or both?
  • Are you using any birth control? Which method do you use?
  • Have you noticed any pain or bleeding during or after intercourse?
  • Do you regularly use condoms to prevent STIs?
  • Have you had any STIs in the past?
  • Have you noticed any sores around the vagina or unusual vaginal discharge?
• OBGYN Hx: Preventative care
  • Have you had regular Pap tests? When was your last one? Have you had any abnormal results?
  • Have you had routine testing for HIV or other STI?
  • Have you received a vaccine for HPV?

Sexual History

• Sexual Hx
  • Adolescents/adults should be asked about their history; with the level of detail appropriate to the reason for the visit
  • Obtain permission! It’s a sensitive topic. Avoid leading/judgmental questions.
  • Remind patients that their sexual history is confidential and not disclosed to others without their permission.
  • Avoid making assumptions; IE., use the term “partner”.
• Sexual Hx: General
  • Are you currently sexually active?
  • Are you active with men, women, or both?
  • Have you been sexually active in the past?
  • Are you currently using birth control? Which method do you use?
  • Do you participate in oral or anal sex?
  • Have you ever had sex in exchange for money or drugs?
• Sexual Hx for STI
  • Do you regularly use condoms (to prevent STI?)
  • Have you had and STIs in the past?
  • Have you had any previous HIV test?
  • Have you noticed any pain, sores, or infections around the genitals?
  • Have you noticed any vaginal or urethral discharge?
• Sexual Hx for abuse
  • Do you feel safe in you current relationship?
  • Have you ever been forced or coerced into having sex?
• Sexual Hx for transgender patients
  • Would you feel more comfortable if I refer to you as a male or female?
  • Are you currently living publicly as a man or woman?
  • Have you undergone any surgeries or hormonal treatments to change your physical appearance?
• Sexual Hx for symptoms or dysfunctions
  • Have you noticed any pain or bleeding during or after intercourse?
  • Do you feel that you have normal interest in sex?
  • Are you satisfied with your sex life?
  • Are you able to achieve and maintain an erection?
  • Do you have normal night-time or morning erections?
  • Are you able to achieve a normal orgasm? with your partner or masturbation?
  • How long have you been attempting to get pregnant?
  • Have you ever been pregnant?

Psychiatric History

• Mood
  • How have you been feeling lately, emotionally? How long have you felt this way?
  • Tell me about what hobbies/interests you have. Do you still have interest/enjoy doing those things? (Anhedonia)
  • Do you spend a lot of time blaming yourself for things you have done wrong? (Guilt)
  • Do you tend to look at things with a positive state of mind, or a negative one? (attitude/pessimism)
• Psychotic symptoms
  • Have you ever heard or seen things that others can’t? (Hallucinations)
  • Have you heard voices talking to you only when nobody else is around? (Hallucinations)
  • Have you ever feared that someone was trying to harm you or that there was a plot against you? (Delusions)
  • Have you ever felt you were receiving special messages from the TV, radio, or internet? (Delusions)
• Somatic Symptoms
  • Have you ever heard or seen things that others can’t? (Hallucinations)
  • Have you heard voices talking to you only when nobody else is around? (Hallucinations)
  • Have you ever feared that someone was trying to harm you or that there was a plot against you? (Delusions)
  • Have you ever felt you were receiving special messages from the TV, radio, or internet? (Delusions)
• Stressors & Support
  • Is there anything in your life lately that has been difficult to cope with?
  • Do you have anyone to talk to when you feel this way?
  • Have you had any difficult or traumatic events recently?
  • Were you ever physically, sexually, or emotionally abused?
  • (Screen for PTSD) Have you ever experienced an extremely traumatic event, which you currently continue to reexperience in the form of flashbacks or nightmares?
• Memory
  • How is your concentration and memory?
  • Do you have difficulty reading or following a conversation?
  • Do you feel like you are frequently forgetting things?
• Functional status/relationships
  • How are your symptoms affecting you relationships and work?
  • How are you doing on your job? Taking care of your home? Paying your bills?
  • How are things going in your family?
  • How is your sex life?
• Insight/readiness
  • What do you think the main problems might be for you?
  • What could these problems be due to?
  • What do you think should be done to help your problems?
• Assessment of risk
  • (Suicide — ask ALL patients with psychiatric symptoms)
  • Have you ever considered ending your life?
  • Do you have any plans regarding ending your life?
  • (Past suicide attempts) Have you ever attempted to harm or kill yourself?
  • Do you have any pills or guns at home?
  • (Partner violence) Do you feel safe in your relationship?
  • Do you have a safe place to go when you feel threatened?
• Substance use issues
  • Obtain details of use: Quantity, frequency, route, treatment attempts, longest period of sobriety
  • Obtain date of last use for each substance used (for withdrawal assessment).
  • Ask questions to determine the temporal and causal relationship of substance use to psychiatric symptoms.
• Documentation
  • Appearance/dress — well groomed, disheveled
  • Alertness/orientation — alert, distractible, somnolent, oriented to person/place/time
  • Behavior/psychomotor activity — good/poor eye contact, cooperative, guarded, restless, agitated
  • Speech — soft, loud, fluent, pressured
  • Mood — dysthymic, anxious, expansive
  • Affect — flat, restricted, labile
  • Suicidality — ideation, intent, plan
  • Psychotic features — auditory, visual hallucinations, paranoid delusions
  • Thought process — tangential, disorganized, flight of ideas
  • Cognition
    • – Memory – recent and remote (recent events, recalls 1 of 3 objects, confabulation)
      • Concentration (number of errors with serial 7s, “WORLD” spelled backward)
      • Estimate of intelligence (fund of knowledge, knows recent presidents, current events)
      • Abstraction (concrete interpretation of similarities, proverbs)
      • Insight (acknowledges illness, denial, blaming)