History Taking

Copyright Medical School Forum 2007

Principles of Taking a History of a Patient

Taking a patient’s history is thought to be the most important skill in medicine you can learn. It is the center of the patient-doctor relationship and a key factor in the establishment of a diagnosis from the information you receive directly from the patient.

We will briefly outline the steps in order to take a history of a patient. Steps in Taking a Patient's History The History Taking Sequence

There are no steadfast rules to take a patient's history, however this is a good template to follow when taking a history. History Introduction

Wash Hands

Wash your hands before you see the patient.

Introduce Yourself

Make sure you introduce yourself to the patient in a warm and friendly manner, shake their hand, giving your name and your medical school status (what year you are in as a student etc.). If you do not see the patient's name on charts or whiteboard, ask the patient’s name.

Don't forget to ask for the patients permission to take a history (consent). Confirm that the information given will remain confidential (confidentiality). Presenting Principal Symptoms (PS)

(Presenting principal symptoms is also called presenting complaint)

You next need to establish what was the principal (main) symptom that caused the patient to seek medical attention.

Good questions to ask are opened-ended questions such as:

What was the main problem that made you want to see the doctor / come to the hospital? Or

What has been the problem recently?

Also ask: When did you first notice the problem? (date / time)

As the symptom(s) are mentioned by the patient, make sure that you get the following information for each symptom:

History of the Presenting Illness (HPI)

Time of onset of Symptom

Questions to ask:

When did the [pain] first appear and how it has changed over time? Duration

How long did the pain last? Mode of Onset

Pain can be rapid onset, gradual, or instantaneous.

Did the pain come about suddenly or gradually? Site of Symptom

Where is the pain located? Character

Does the pain feel burning, dull or sharp? Severity of Symptom

On a scale of 1 to 10 describe your pain? Aggravating / Relieving Factors

Is there anything that makes pain worse or better?

Quantify Severity

Shortness of breath quanitfy walking length / stair number

also ties into: Impact of Illness of Lifestyle

Extent of disability / Effect on daily life

Make sure you also ask:

When did you last feel fit and well?

How do you feel at the moment?

Have you seen a doctor before for the same problem?

Systems Review (SR)

General

Genitourinary

Cardiorespiratory

Central nervous system

Gastrointestinal

Locomotor

Past History (PH)

Past History of patient.

Have you had any similar episodes in the past?

Have you had any serious illnesses, operations, hospital visits?

Ask if relevant: Do you have Epilepsy or Diabetes? Previous Heart Attack? Did you have cancer?

Have you had any other medical problems or conditions? Drugs and Allergies

Social History

Family History

Ideas and Concerns

General History Sequence Order Mnemonic

I PS HPI SR PH SH FH

ISHSPSF Introduce get Symptom, History of Symptom, Systems, Past Symptoms, Drugs, Social and then Family history.