Learn the basics of good medical history taking.

The Basics of A Good Medical History

How to Begin to Take a Good History 

In order to take a good history and make a satisfactory physical examination, the medical student must have a method and be fully conscious of what he is trying to do.  The primary object of the history and examination is to determine in what way the patient is unwell and , if possible, the character and situation of his trouble.  The patient comes to the physician with some complaint from which he seeks relief.  In the 'History of Present Illness' an attempt is made to analyse this complaint completely and to correlate it with other symptoms and signs which may be discovered.  This is followed by the 'Functional Enquiry' in which one enquires in a detailed fashion into the functional efficiency of the various organs and systems; next, the 'History of Past Illnesses', Personal History (Social History) and Family History, which indicate in what manner these may have contributed to the present condition of the patient.  A good history is of invaluable help in solving the problem presented.

After the 'History' comes the 'Physical Examination' in which one examines the physical state of the patient from head to foot.  When the history and physical examination of the patient have been completed, the physician should be fairly well qualified to answer the patient's question: "Doctor, what is the matter with me?", and to treat him intelligently.

The following scheme is meant to act as a guide for the carrying out of such an investigation, indicating the order in which it is suit- able to conduct the enquiry and the examination.  It does not pretend to be complete in any respect and for details the student will have to rely upon his theatre clinic notes, his bedside teaching in the wards of the hospital and the various text-books on medicine and allied subjects.

It is perhaps unnecessary to point out that the method of taking a history and conducting a physical examination will vary depending upon the acuteness or chronicity of the illness.  In the acutely ll patient, one must direct the attention, examination, and treatment mainly to the regions involved, leaving the more exhaustive enquiry and examinations at such as those of the nervous system in a person having haemoptysis, gastrointestinal haemorrhage or pneumonia at until such time as the patient can be subjected to this without any undue fatigue or distress.  In the chronically ill patient, on the other hand, it will probably be necessary to go fully into all the details of enquiry and physical examination before a final conclusion can be reached.

It should be emphasized, too, that the student should at all times be tactful, considerate, and kind, and that he should be mind- ful of the fact that he is dealing with a person who has a disease and not with a disease alone.

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