History Taking Skills
Grzegorz Chodkowski (MD)
Riga, Radisson SAS
History Taking Format
– Chief complaint – History of present illness (HPI) – Past medical history, which includes • Childhood • Medical • Surgical • OB/GYN • Psychiatric – Family history – Medications – Allergies – Personal/social history – Review of systems
problem / condition that motivated patient to seek care
To elicit the chief complaint, ask broad questions: – What brings you in today? – Tell me what has been going on. – What seems to be the problem? – What are your complaints?
History of the present illness (HPI)
• Patient's age, sex, occupation • Symptoms (or immediate cause of admission) • Chronology and the seven characteristics of the current symptoms: -Anatomic location -Quality -Quantity or severity -Timing -Setting in which the symptoms occur -Aggravating or relieving factors -Associated symptoms
History of the present illness (HPI)
Use facilitating expressions to encourage the patient to continue: – Mmm Hmm. – Yes? – Uh Huh? – And what else? - I am with you – Listening body language
Once the patient has had a chance to tell his or her story you can move on to more directed questions to clarify.
• • • • •
What is wrong? Where is it wrong? When did it start going wrong? How did it go wrong? Why do you think it is wrong?
Directed or closed questions
– Multiple choice • Do you have nausea, vomiting, constipation or diarrhea? • Is the pain sharp, dull or shooting? • Have you had this for days, weeks or months? • How long is the pain: minutes or hours? Important: Pause to wait for each response!!
Yes or No questions • Do you have diarrhea every day? • Do you have any allergies? Quantitive questions
• How many loose stools do you have a day?
Avoid leading questions – You don’t smoke do you? – You haven’t had any chest pain? – Your wife is your only sexual partner, right? Avoid compound questions – Do you have trouble sleeping? How much sleep do you get? – Do you use cocaine, marijuana or alcohol?
L : Location O : Other symptoms C : Characteristic of the symptom A : Aggravating or alleviating factors T : Timing E : Environment S : Severity
• Where does it hurt? • Which part of your chest/head/abdomen is affected? • Does it stay in one place or does it radiate anywhere else?
Pertinent positives and negatives to help you rule in or rule out disease Associated symptoms Other new symptoms that may not be related
• • • • • Apart from your chest problem are there any other problems How’s your appetite? Do you have any problems with passing water? Are your bowel motions regular? Have you noticed any blood in your stools?
-quality of the symptom
Get the patient to use their own descriptive words if possible.
– What does it feel like? – What kind of pain is it? – Can you describe the pain? – Does it affect your sleep/work? – How often are the attacks? – Is the pain continuous or does it come and go?
Aggravating And Alleviating Factors
– What makes it better?
– What makes it worse? – What has the patient done to try to feel better? – What seems to bring the pain on? – Does anything make it better / worse ? – Is the pain relieved by drugs / rest / changing position? – Have you taken any medicines for the pain? (over the counter medications, friend’s medication)
Timing: Onset & Duration
– When did it start? – How long have you had this pain? – When did you first notice it? – Is it intermittent or continuous? – How long does each episode last? – Does the symptom vary with time of day? – Have you ever experienced this before? - Associations with specific events
– What places or events affect the symptom? – Work vs. home – Leisure activities – Diet – Emotions – Heat, dust, altitude
– How is the symptom interfering with the...
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