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Author: Kanchan Ganda, M.D.

1. Introduction

The purpose of history taking and physical examination as stated earlier is to collect information from the patient, examine the patient, and to understand the patient’s problems.

The traditional history taking has several parts, each with a specific purpose. In order to achieve maximum success, the medical history must be accurate, concise, and systematic. Following is a STANDARD outline of the different components of history taking in sequential order.

The introductory materials in the health history consist of collecting the following information from the patient:

1.1. Data Collection

The following information is obtained in all patients to gain a basic understanding of the patient:

Date of visit: Record number:
Name (last): (first): (middle):
Home address:
Business address:
Occupation:
Date of birth:
Sex:
Marital status (S/M/D/W):
Height: Weight:
Referred by:

1.2. Chief Complaints

Described in the patient's own words the reason for seeking care:

e.g.; "I have a toothache" or "I need routine cleaning" or "I need a root canal"

1.3. Present History

List in clear chronological order, the details of the problem or problems for which the patient is seeking care. You will determine by interrogation the time line of:

  • When did the patient’s problem(s) begin?
  • Where did the problem begin?
  • What kinds of symptoms did the patient experience?
  • Has the patient taken any treatment for the problem?
  • Has the treatment had any effect on the patient or has the treatment not improved or altered the patient’s condition?
  • It is also important to determine if the problem(s) have affected the patient’s lifestyle. that is, have the symptoms experienced because of the problem(s) caused any incapacities?

1.4. Past History

Gives you an insight about the health status of the patient up until now. Check with the patient for the presence or absence of the following conditions by eliciting the symptoms and signs associated with those conditions:

  • Anemia
  • Bleeding disorders
  • Cardiorespiratory disorders:
    • Angina, Myocardial Infarction, TIA (Transient Ischemic Attacks), CVA (Cerebro Vascular Attacks /stroke), Hypertension, rheumatic heart disease, Asthma, tuberculosis, bronchitis, sinusitis, chronic obstructive pulmonary disease (COPD).
  • Drugs/medications:
    • Determine the list of current medications that the patient is taking:
      • Prescribed
      • Herbals
      • Over-The-Counter (OTC) medications
      • Also determine if the patient is currently on steroids or has the patient been prescribed any corticosteroid preparations within the past two years. Check if the patient has any known allergies to any drugs like NSAIDs, aspirin, codeine, morphine, penicillin, sulpha, or any local anesthetics.
  • Endocrine disorders:
    • Common disorders to be ruled out (in the medical lingo, it means to establish that a disease is not present) in the patient are: diabetes, hyperthyroidism, hypothyroidism, adrenal disorders—Addison’s disease or Cushing’s syndrome.
  • Fits or faints:
    • Rule out different kinds of seizures in the patient—grand mal epilepsy, petit mal epilepsy, temporal lobe or psychomotor epilepsy, or localized motor seizures.
  • Gastrointestinal disorders:
    • Rule out oral ulcerations, esophagitis, gastritis, peptic ulcerations, Crohn’s disease, coeliac disease, ulcerative colitis, polyps, hemorrhoids, etc.
  • Hospital admissions:
    • Determine the cause or causes for admission. Did the patient have any history of accidents or injuries? Was the patient given any anesthesia—local/general? Were there any complications during the hospital admission due to the anesthesia or the medical/surgical condition? Was the patient given any blood transfusion during hospitalization?
  • Infectious diseases:
    • Check for Infectious diseases of childhood: like measles, mumps, chicken pox, strep pharyngitis, rheumatic fever, scarlet fever. Check for Infectious disease of adulthood: STDs (sexually transmitted diseases), hepatitis (especially viral hepatitis), HIV infection, infectious mononucleosis
  • Immunological diseases:
    • Lupus, Sjögrens syndrome, rheumatoid arthritis, polyarthritis nodosa, etc.
  • Jaundice or liver disease:
    • Has the patient developed jaundice due to viral hepatitis or alcoholic hepatitis, gall stones, etc.? Is there any history of gall bladder dysfunction? Is there any indication of improper liver function?
  • Kidney disorders:
    • Is there any indication of kidney dysfunction or renal stones, urinary tract infections, or renal failure or renal transplant?
  • Likelihood of pregnancy
  • Musculoskeletal disorders:
    • Osteoporosis and other causes of impaired bone metabolism; Paget’s disease; osteoarthritis; rheumatoid arthritis; psoriatic arthritis; gout; muscular dystrophies; polymyositis; myasthenia gravis, etc.
  • Neurological disorders:
    • Cranial nerve disorders; headaches and facial pains, including migraine; multiple sclerosis; motor neuron disease; TIA (transient ischemic attacks) or CVA (cerebrovascular accidents) associated neurological deficits; Parkinson’s disease; peripheral neuropathies
  • Obstetric and gynecological disorders:
    • Is there any significant condition or disease(s) that can lead to bleeding or anemia; any tumors needing chemotherapy or radiotherapy.
  • Psychiatric disease:
    • Personality disorders, neuroses, anxiety, phobias, hysteria, psychoses, schizophrenia, PTSD (post traumatic stress disorder)
  • Radiation therapy
  • Skin disorders:
    • Lichen planus, phemphigus, herpes simplex, herpes zoster, eczema, unhealed skin lesions or urticaria (itching of the skin)
  • Tetanus immunization/hepatitis immunization/influenza immunization
  • Violence:
    • Domestic violence; elder abuse; child abuse
  • Wound healing

1.5. Personal History

In this part of the history one tries to get an insight into the patient’s lifestyle, occupation, and habits:

  • In the lifestyle component an attempt is made to understand what constitutes a typical day for the patient. What does the patient do for recreation, relaxation, etc.?
  • What kind of job does the patient have? Are there any job-related toxic exposures that exist?
  • Is there any history of alcohol intake? How much? Coffee/tea intake? How much? Any history of diarrhea, vomiting?
  • Is there any history of smoking cigarettes or using “recreational” drugs like marijuana, cocaine, amphetamines, etc.
  • Has the patient ever used IV drugs? Has he ever swapped needles?
  • Has the patient been exposed to any infectious diseases or sexually transmitted diseases (STDs)?
  • Does the patient use any herbal medications or over-the-counter medications like diet pills, birth control pills, laxatives, analgesics (aspirin, acetaminophen, etc.: pain killers), or cough/cold medication?

1.6. Family History

After the patient’s medical history has been explored, it is important to find out about the health of the immediate members of the family:

  • One has to determine if certain common diseases run in the family, i.e., does a familial pattern exist
  • In this part of the history, you have to determine the age and health of the patient’s parents, siblings and children
  • If any member is deceased, the age and cause of death is established
  • Common diseases, with a strong hereditary component or tendency for family clustering, are sought, e.g., coronary artery disease( CAD), heart disease, diabetes mellitus (DM), hypertension (Htn), stroke (CVA), asthma, allergies, arthritis, anemia, cancer, kidney disease or psychiatric illness

1.7. Review of Systems (ROS)

In this portion of the history, all organ systems not already discussed during the interview are systematically reviewed. ROS is a final methodical inquiry, prior to physical examination. It provides a thorough search for further, as yet unestablished, disease processes in the patient. If the patient has failed to mention symptoms, this process of ROS would remind the patient at this point. Also, if you have unknowingly omitted certain points of inquiry, now would be the time to establish those.

Following are the topics to be reviewed for each organ system:

1.7.1. Constitutional

  • Any history of recent weight change
  • Any history of anorexia (loss of appetite), weakness, fatigue, fever, chills, insomnia, irritability or night sweats

1.7.2. Skin

  • Any history of skin rashes—acute or chronic, is it unilateral or bilateral
  • Any history of allergic skin rashes
  • Any itching of the skin
  • Any history of unhealed lesions (probably due to: diabetes; poor diet; steroids and other causes of decreased immunity, especially AIDS)
  • Any history of bruising, bleeding

1.7.3. Head

  • Any history of headaches
  • Loss of consciousness (may be due to cardiovascular, neurologic causes, anxiety, metabolic causes, etc.)
  • History of seizures. Are they general (with or without loss of consciousness) or focal? Are there any motor movements?
  • Is there any history of head injury?

1.7.4. Eyes

  • Check for vision, history of glaucoma ( could cause pain in the eyes), redness, irritation, halos (seeing a white ring around a light source), blurred vision
  • Any irritation of the eyes, excessive tearing, which can be associated with frequent allergic symptoms?

1.7.5. Ears

  • Any recent change in hearing
  • Any pain in the ears or ringing in the ears (tinnitus)? discharge?
  • Any history of vertigo (dizziness)?

1.7.6. Lymph Glands

  • Any history of lymph glandular enlargement in the neck or elsewhere? Are they tender/painless? How were they first noticed?
  • Are they freely mobile or are they adherent to the underlying tissues?

1.7.7. Respiratory System

  • History of frequent sinus infections
  • Postnasal drip
  • Nosebleeds
  • Cough (with/without expectoration)
  • Color of sputum, when present
  • History of sore throat
  • History of shortness of breath on exertion or at rest
  • Any history of wheezing (may be due to asthma, allergies, etc.)
  • Hemoptysis (blood in the sputum): may be due to dental causes; lung causes like bronchitis, tuberculosis; cardiac causes like mitral stenosis or CHF (congestive heart failure). Determine if it is a blood-tinged sputum or there is frank blood in the sputum.
  • Any history of bronchitis, asthma, pneumonia, emphysema, etc.

1.7.8. Cardiovascular System

  • History of chest pain or discomfort
  • History of palpitations: were the palpitations associated with syncope (loss of consciousness)?
  • History of either hypertension or hypotension
  • Does the patient experience any paroxysmal nocturnal dyspnea (shortness of breath during sleep, in the middle of the night)? Is there any SOB in relation to exercise or exertion?
  • Any history of orthopnea (shortness of breath when lying flat in bed)? Does the patient use more than one pillow to sleep? Has this always been the case, or has the patient recently started using more pillows?
  • History of edema (site of edema—legs, face, etc.)
  • Any history of leg pains, cramps? Are they relieved by rest (this is suggestive of intermittent claudication) or is it unremitting? (this is muscular)
  • Any history of murmur(s), rheumatic fever, varicose veins?
  • Any history of hypercholesterolemia, gout, excessive smoking, i.e., conditions which can lead to or worsen heart disease

1.7.9. Gastrointestinal System

  • History of bleeding gums, oral ulcers or sores
  • History of dysphagia (can the patient point out and describe where the difficulty swallowing exists?)
  • History of heartburn, indigestion, bloating, belching, flatulence
  • History of nausea: is it related to food? Is it one of the many symptoms due to GI (gastrointestinal) disease?
  • Vomiting: is there any associated weight loss, psychosocial factors, or are medications causing it?
  • Hematemesis (vomiting blood). Ask for associated ulcer history, food intolerance, abdominal pain or discomfort
  • Jaundice: is there a viral cause, gallstones, associated family history?
  • History of diarrhea/constipation
  • Any change in color of stools

1.7.10. Genitourinary

  • History of polyuria (excessive urination) due to diabetes, renal disease, unknown cause, etc. Check if this has been a recent change
  • History of nocturia (getting up at night to go to the bathroom). Is this a recent change?
  • History of dysuria (painful urination). If it is because of urinary tract infection (UTI), the patient will experience frequency and urgency in addition to dysuria. STD will also be associated with similar symptoms (was treatment for STD completed?)
  • History of renal stones, pain in the loins, frequent UTIs

1.7.11. Menstrual History

  • Date of LMP (last menstrual period). Always precede this question by informing the patient that she has to get x-rays done, so you need to know if she is pregnant; thus, the need to know her LMP
  • Any history of menorrhagia (heavy periods)
  • History of use of birth control pills

1.7.12. Musculoskeletal System

  • History of joint pains—determine location: is it acute or chronic? Unilateral or bilateral? More in the morning or evening? Are there associated systemic symptoms?
  • Any history of rheumatoid arthritis, osteoarthritis, gout, etc.

1.7.13. Endocrine System

  • History of symptoms due to diabetes, i.e., polyuria, polydypsia, polyphagia1, weight change
  • History of thyroid symptoms: heat/cold intolerance, increased/decreased heart rate, goiter, etc.
  • History of adrenal symptoms: weight change, easy bruising, hypertension, etc.
  • 1 Polyuria — excessive urination; polydypsia — excessive thirst; polyphagia — excessive appetite

1.7.14. Nervous System

  • History of stroke, CVA, TIA
  • History of muscle weakness, involuntary movements: they may be tremors, seizures, or anxiety, etc.
  • History of sensory loss of any kind: anesthesia, paresthesias, or hyperesthesias2
  • Is there any change in memory, especially recent change.
  • 2 Anesthesia no sensation; paresthesia altered sensation, commonly a pins and needles sensation; hyperesthesia increased sensation

1.8. Concluding History

It is important at this point to collect the relevant data about the patient (all positive findings) and construct a logical framework of the case.