Dr.

Tariku Fekadu

OVERVIEW OF MEDICAL HISTORY

TAKING IN ADULT PATIENTS

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General principles in history
taking
 Greet patients and introduce yourself
 Establish a good relationship-treat patients politely
and considerately ; respect their right to
confidentiality
 Interview in a logical manner
 Start with open-ended questions
 Listen carefully
 Interrupt appropriately( allow the patient to tell the
whole story, then ask question to fill in the gaps)
 Note and provide non-verbal cues
 Correctly interpret the information obtained
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Outline of medical case report
 Identification of the patient
 Source and reliability of history
 Previous admissions
 Chief complaint( C/C) or presenting complaint
 History of present illness( HPI)
 Past medical history
 Functional inquiry( review of systems)
 Personal and social history
 Family history
 Physical examination
 Summary ( subjective and objective components)
 Differential diagnosis(DDx)/ problem list
 Discussion of differential diagnosis
 Diagnostic impression
 Investigations
 Plan of management
 Progress notes and discharge summary 3
Identification of the patient
 Full name (including grandfather)
 Age
 Sex
 Occupation
 Address
 Marital status
 Ethnicity
 Religion
 Ward and bed number
 Card number
 Date and time of admission
 Nature of admission( emergency/non-emergency)
 Referral 4
Source and reliability of
history
 Source- patient? Relatives/attendants?
Directly or with interpreter?
 Reliability ?

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Previous admissions

 List previous admissions in chronologic order

stating hospital, date/year of admission,
diagnosis , treatment given and outcome
briefly

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Chief complaint

 The major symptom/concern( with its

duration) that caused the patient to seek
medical care
 What is your main problem /symptom?
 What problem has brought you to hospital?
 Should be stated in the patient’s own words
 E.g.. ‘’fever of 2 days duration” , “cough and
SOB of one week duration”

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History of present
illness(HPI)
 Should begin by ascertaining when the patient
was last perfectly or relatively well and should
continue with the details of the presenting
symptoms in chronologic order
 Patient's words should be used when possible

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 …HPI
 DESCRIBE symptoms in terms of :
 Date of onset
 Mode of onset, course and duration
 Character ,severity and location
 Exacerbations and remissions
 Precipitating(aggravating) and relieving factors
 Effects of treatment
 Associated symptoms
 Positive-negative statements

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 Date of onset:
 You may start the HPI with the phrase “the patient was
perfectly or relatively well until….”

 Mode of onset, course and duration: Ask whether the onset

was:
 abrupt or gradual ƒ
 intermittent or persistent ƒ
 short lived or long standing ƒ
 steady or increasing in severity.

 Location: Where is it? Does it radiate?

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 Exacerbating and Remitting Factors:
 Eg. exertional chest pain and relieving during rest
 Associated manifestations
 Have you noticed anything else that accompanies it?

 Effect of treatment:
 Patients might have taken medications prior to their presentation
 Include the name, dose, route, and frequency of use.
 Ask about the effect of such drugs on the illness.

 Negative- Positive statements:

 used to construct differential diagnosis and their complications
 A negative statement may be as important as a positive statement.

 NB: Avoid medical terminologies

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Past history

 This includes important illnesses from infancy onwards.

 Illnesses experienced during adulthood.
 Surgical History /Operations. ƒ
 Medical history: HTN, DM, epilepsy, TB treatment,

 Gynecologic and Ostetric history:

 STI (eg-Syphilis), AUB,
 Abortion, GDM, pre-eclamptia

 History of blood transfusion, Allergy

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Personal and social history

 Early development –place of birth, childhood devt,

 Education –school history, achievements
 socioeconomic status (income)
 Environment –living conditions
 Social activities – recreation and other activities

 Habits:
 history of substances like alcohol, tobacco, chat, etc.
 try to quantify the daily alcohol and tobacco consumption.
 For alcohol abuse disorder, use CAGE criteria
 For smoking, put in pack year(No of pack smoked/day X No of yrs smoked)
 Dietary habit

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Family history

 Any familial disease/running in families

 e.g. HTN, DM, schizophrenia, asthma,
 communicable -- TB

 Father and mother-age, health status, cause of death(if

died)

 Siblings: If dead, mention the date and possible cause of

death
 Sudden cardiac death

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Functional inquiry/Review of systems

 General: change in weight, fatigue , fever, sleep

disturbance
 HEENT: Head- headache, head injury, dizziness,
lightheadedness Eyes- visual disturbances, pain
and redness in the eye, eye discharge,
lacrimation, photophobia, itching; Ears-earache,
hearing difficulty, ear discharge, tinnitus, vertigo
Nose- nasal stuffiness, discharge, epistaxis,
itching Throat and mouth- gum
swelling ,bleeding and pain, dental ache, sore
tongue and throat, dryness of mouth
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 ……..
 Glands: enlarged lumps/swellings in the neck, armpits,
groins; breast lump, discharge; cold and hot intolerance
 Respiratory system: cough, sputum( color, quantity, odour),
chest pain, SOB( dyspnea), hemoptysis, wheezing
 Cardiovascular system: SOB(dyspnea), orthopnea,
paroxysmal nocturnal dyspnea(PND),palpitations, chest
pain, syncope, edema, intermittent claudications
 Gastrointestinal system: difficulty or painful
swallowing( dysphagia and odynophagia), appetite,
nausea, vomiting, indigestion, heart burn, abdominal pain,
diarrhea , constipation, yellowish discolouration of
eyes( jaundice), change in the colour of stool, vomiting of
blood( hematemesis) 16
 …..
 Genitourinary system: burning pain on passing urine(
dysuria), frequency of urination, passing large
volumes of urine( polyuria),decreased urine volume,
urgency, incontinence, difficulty in micturition,
hesitancy, dribbling, change in the colour of urine,
nocturia, flank pain, menstural history in women:
menarche, interval between periods, duration of flow
and amount of flow, or menopause; dyspareunia ;
urethral discharge, vaginal discharge, ulcers/lesions
on genitalia, testicular pain/mass
 Integumentary system( skin, hair, nails): skin
rash/lesions, bruising, discolouration, itching,
dryness; changes in hair and nails
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 ……
 Locomotor system( musckulo-skeletal system):
pain, swelling or stiffness of joints; muscle aches,
back aches, leg swelling, joint or bony deformities
 Nervous system: fainting, abnormal body
movements( fits, seizures), weakness or paralysis
of limbs, numbness/ tingling/ pain over limbs,
difficulty of memory and concentration, visual
disturbance, diplopia

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Physical examination
 General appearance
 Vital signs: weight, height, calculate BMI, PR, RR,BP,
temperature, oxygen saturation
 HEENT
 Glands
 Respiratory system/ chest
 Cardiovascular system
 Gastrointestinal system/ Abdomen
 Genitourinary system
 Integumentary system
 Locomotor system/ musculo-skeletal system
 Nervous system 19
 Summary
 Subjective- relevant points from the history
 Objective- relevant points from the physical
examination

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 Differential
diagnosis/problem list
 List of diagnostic possibilities explaining the
patients problems
 Should be listed in order of likelihood

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 Discussion of DDx
 Logical arguments for and against diagnostic
possibilities based on history physical
examination and basic investigations

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 Diagnostic impression
 Likely diagnosis

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 Investigations
 Necessary tests- laboratory, imaging, special
tests

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 Plan of management
 Non-pharmacologic and pharmacologic
treatments

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Progress notes

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Discharge summary

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