History-taking can be defined as an interview of a patient. In other words, it refers to knowing the things which a patient knows about his or her illness. There is no confined method or pattern while talking about my history as symptoms of the patient vary according to the patient’s disease for example the history of a patient suffering from fever is never the same as the one who is having some issue regarding the cardiovascular system. In general, a stepwise procedure is followed while taking history which will help you in taking history while you go for taking patients’ history inwards and in general too.
What guidelines you must follow while taking the history of the patient
• Your behaviour with the patient must be empathetic and not compassionate.
• Be friendly with the patient.
• Be confident and never utter words such as ” I think “and” maybe ” so that the patient can believe what you are saying.
• Never interrupt patients’ activities for example eating. Wait for him to be free.
• Don’t interrupt while the patient is telling about his or her disease.
• Build healthy relationship with the patient so that he came to tell your every minor thing about his symptoms as it will help you diagnose the disease.
• Always try to talk in a language that the patient can understand easily.
• Mark an estimation of the personality and nature of the patient and similarly talk to him.
• Don’t ask for leading or closed-ended questions instead ask open-ended questions. For example, instead of asking “are you feeling pain in the thorax or abdomen”? ask,” have you got any pain anywhere”?
• Encourage the patient to give details about his or her disease. You can also encourage them by telling them that this information will help you to make a proper diagnosis and the patient will recover speedily.
• Avoid writing while the patient is telling you about his disease as it gives an impression that you are not attentive. An alternative is that you tell the patient that you are writing this so that you may not forget. In this case, write in the form of points and then compile them according to the pattern given below.
• Confidentiality of the patient must be maintained.
• If the patient is unconscious or a little child, take a history from the attendant of the patient.
• Always introduce Yourself to the patient and greet them before taking history.
In which 10 steps history should be taken?
This sequence is simply followed just to make sure that no point is missed while taking history. A general pattern followed while taking history is as follows:
1. Biodata of the patient
2. Presenting complaints
3. History of present illness
4. Systemic inquiry
5. Past history
6. Menstrual history (if the patient is a female)
7. Treatment history
8. Family history
9. Personal and social history
10. Occupational history
Now we will discuss each of these steps separately.
Biodata of the patient
Ask for the complete name, (with the father’s name and the name of the husband in case of a female) age, and sex(You can guess the gender of the patient by looking at him or her as it seems weird to ask about the sex of a person but in case of any confusion you can confirm it from the patient), marital status (married or unmarried) complete address and occupation.
Importance of biodata in history
• The name gives the identity of the patient.
• Age helps in diagnosing some diseases because some diseases are age-related.
• Sex is important because some diseases are common in one gender and uncommon in another gender. For example, autoimmune diseases let me lupus erythematosus is common in females.
• Occupation tells not only the educational but also the economical background of the patient.
Presenting complaints
It includes the complaints that made the patient come to the hospital. You can ask the patient: “what is the thing that made you visit the hospital?”
The complaints must be written in chronological order i.e the symptom which developed first must be written at the top and the one which developed most recently must be written at the bottom.
Here is an example:
Fever : 2 days
Shortness of breath and cough :1 day
History of present illness
In this section, you will write the history of the above-mentioned complaints in the order in which they developed.
Every symptom has its history which helps us diagnose the disease.
Here is a mnemonic DOPARA, you can use this to memorize the points you have to ask for a particular complaint.
DOPARA stands for the duration, onset (slow or acute), progression, associated symptoms, relieving factors and aggravating factors.
Warning: No medical term should be used while taking History of present illness as you are writing in the language of the patient.
Note: This is just a general overview of the history of the present illness. In practice, each symptom has its specific questions which help in diagnosing the disease.
systemic inquiry
The systemic inquiry also called a review of symptoms. Itincluds following systems
- Cardiovascular system
• Locomotor
• Urinary
• Central nervous system
• Respiratory system
• A general inquiry about appetite, any weight gain or weight loss, and regulation of the sleep-wake cycle etc.
How I will know about the integrity of various systems of the body?
You are not gonna ask about the integrity of the patient’s systems. instead, you will ask about different symptoms from the patent and assess the integrity of various systems. This includes:
Respiratory system
Ask the patient about:
• Cough
• Sputum
• Blood in sputum
• Breathlessness
• Any Whistling breath Sounds
Gastrointestinal system
• pain in abdomen
• Vomiting
• Blood in vomiting
• Difficulty in swallowing /degulgitation
• Nausea
• Constipation
• Frequent loose stools
• Jaundice
• Heartburn
Cardiovascular system
• Shortness of breath
• Pain in chest
• Rapid heartbeat
Urinary system
• Burning urine
• Vomiting
• Vomiting
• Blood in urine
Locomotor
• Immobility
• Swelling
• Pain in joints
Central Nervous System
• Tingling sensation
• Numbness
• Weakness
• Fits
Past History
Ask about health issues which occurred earlier and were not part of presenting complaint.
It includes:
• Vaccination
• Any significant disease
• Surgery
• Hospitalization due to any significant disease
Menstrual History
Ask the following questions from a female patient :
1. What was the age of onset of menstruation?
2. What is the length of the menstrual cycle(days between the commencing days of two consecutive cycles)?
3. Is cycle regular?
4. Is there any pain associated with bleeding?
Treatment history
Ask the patient if he has already been taking medicine. Patients usually don’t remember the names of drugs. In such cases, you can ask for a prescription from doctors or any leftover medicine.
It helps to diagnose the existing disease of the patient.
Family History
It is important to ask about the health of the parents and siblings of the patient because some diseases are predisposed by genetics for example hypertension, diabetes mellitus and ischemic heart disease.
Personal and Social History
In this section, seek information like:
• What is economic status of the patient
• Any addiction like smoking or alcohol intake
• Family relations
Occupational History
Ask the patient:
• Nature of present job
• Nature of job in past
• Any exposure to radiation or chemical?
Conclusion
One should follow this sequence while taking history so that no point gets missed because history leads a doctor to a proper diagnosis. Hope you enjoyed reading this article.
