The purpose of taking the history & doing a physical examination is to arrive at a diagnosis, which will then help us in selecting the proper treatment. To establish a correct diagnosis, we need to:
1. Take a detailed history,
2. Conduct proper physical examination
3. Advice relevent investigations.
Points to remember before you begin to take the history.
1. History taking is a special form of art of communication.
2. It is the beginning of “Doctor-Patient Relationship” & mutual trust.
3. Always be polite & courteous while taking history.
4. Use right words & body language ( stance, gestures & expression )
5. Ask the patient if they want to talk in private.
6. Keep an attendant or a interpreter ( if required ).
7. Nod your head while the patient speaks & encourage him to speak.
8. Never interrupt the patient.
9. Be patient with the patient.
10. Note down the salient features in the history.
Patient’s history should be asked under the following points
1. Name & Address
2. Age & Marital status
3. Profession ( occupational history )
4. Presenting or chief complaint.
5. History of present illness
6. History of previous illness
7. Treatment history
8. Family history
9. Social history
10. Personal history
If the patient complaints about pain, ask about the following points:
1. Site – Fixed or changing / localized or vague ( Don’t forget referred pain )
2. Radiation – ( Pain may radiate to left arm or neck / mandible in Angina )
3. Severity – Mild / Moderate / Sever, ( Does it disturb sleep / Work )
4. Timing – When did it start ? When does it come / go ?
5. Character – Stabbing / Burning / Pricking / Piercing / Dull aching / Funny
6. Aggravating factors – What brings it on ? What makes it worse ?
7. Relieving factors – What makes it better ? Change of posture / Medication
While taking history try to observe:
1. General Appearance – Generally healthy / Unwell / critically ill
2. Expression & Mental state – Relaxed / Depressed / Anxious
3. Intelligence – I.Q.
Routine Questions to be asked while taking the history
Abdomen / Gastrointestinal system
• Pain – Location / Severity / Radiation / Continuous or intermittent / relation to meals / what aggravates / relieves it ?
• Appetite – increased or reduced
• Vomiting – Frequency / relation to pain & meals
• Characteristics of Vomitus – Amount / Color / Does it contain frank blood / Does it look like “coffee ground” ( suggest bleeding )
• Flatulence – Does wind tend to escape upwards or downwards ? Does it relieve to symptoms ?
• Heart Burn – Relation to meals / what aggravates / relieves it ?
• Dysphagia – Is it more for liquids or solids ? is there pain on swallowing ?
• Diarrhea – Frequency / color / Is there any smell / it’s relation to pain & meals / consistence of stools e.g. watery, semi-solid, sticky or rice water
• Constipation – Usual bowel habit / has there been a recent change ? does it alternate with diarrhea / Is he on Codine / Is he taking laxatives
• Jaundice – Has there been a change in color of urine? (Taking B-Complex is the commonest cause of yellow urine. Mustard colored urine is suggestive of Jaundice ) Ask is there a skin itch?
• Pain – Location / Severity / Feeling of tightness in chest / Radiation to arm, neck, shoulder / relation to exertion / what aggravates / relieves it ? Is it associated with sweating / a “feeling of impending doom” ?
• Dyspnoea – Severity / At rest or at exertion ( what level of exertion ) / Is it more while lying down at night? ( Paroxysmal Nocturnal Dysponea – PND ) Is there swelling over the feet?
• Palpitation – What brings it on & how long does it last? Does he feel occasional thump in Chest? Does the heart beat fast?
• Cough – Dry or productive? Worst at which time of the day? Painful or not
• Sputum – Quantity / Most produced at which time of the day, Consistency color & odor, Purulent or not? Ever blood stained ?
• Breathing – Is patient dyspnoeic ? at rest or after exertion ( what activities produce exertion )
• Wheeze – Is it present? Is it constant or intermittent / Does anything provoke it? Is it worse at any particular time of day or night?
• Chest Pain – Location / Severity / Is it aggravated by deep breathing or coughing ? What relieves it ? Was it associated with cough, wheeze, dyspnoea ? Was it sudden ?( e.g. Pnumothorax )
• Fit or Blackout
1. Age at first attack? Describe the first attack.
2. When did the second attack occur? Third? Interval between attacks
3. Do the occur in sleep? Does the patient become unconscious?
4. Is there any premonition or aura? What is it’s character?
5. Is the onset sudden or gradual? Does he fall / hurt himself ?
6. Are convulsions present? Are they generalized or localized?
7. Does he bite his tongue, micturate, defecate during the attack?
8. Are there any after-symptoms like sleep, headache or paralysis?
• Paralysis or Stroke
9. Inquire regarding heart disease, hypertension or Diabetes.
10. Was there any premonitory symptoms before the onset?
11. How did the paralysis come on? Suddenly or gradually?
12. Had he any headache or vomiting?
13. It’s site, quality, severity, timing & effect of recent treatment
14. Factors that improve, precipitate, worsen or aggravate it.
15. Are there family problems / Tension / emotional conflict ?
16. Is there h/o recent head trauma / discharge from ear ?
17. Does the patient fear brain tumor ?
18. Is the headache Migrainous ? Is there a family history?
19. Inquire if it is intermittent. Is it getting better or worst.
20. Does it relate to head posture. Is there h/o of trauma.
21. Is there h/o deafness / ear problem / ear discharge?
22. Any other feature suggesting brain stem disease.
Questions to ask while taking history of a lady:
1. Ask if the lady is married / Pregnant.
2. Ask for the Menstrual history – Duration / Flow / Clots / Pain
3. Ask is she is taking any contraceptive pill.
Questions to ask the Mother while taking history for a Child:
1. Ask if the mother if she took any drugs while she was pregnant.
2. Was the child born at home or at a hospital?
3. What was the birth weight of the child? What about milestones?
4. Was the baby breastfed ? For how long?
5. What is the vaccination status of the Child?
6. What are the child’s current habits regarding eating, sleeping, bowel & micturation ?
-Dr. Anupam Yadav