Level 1-Semester 2

Module (Principles of Interprofessional Communication &

Clinical Exposure )
Introduction to History Taking
 Instructor information
• Instructor: Professor Elsayed Abdelfattah

• Contact: Internal medicine Department.

• Official email: [email protected]

• Academic hours:

……………day: 00:00-00:00 AM

…………...day: 00:00-00:00 AM
 Lecture Outline
• Case scenario
• Essentials before and during history taking
• Value of history taking
• Personal history
• Complaint
• History of present illness
• Past medical history
• Family history
• Case discussion
• Questions
Learning Outcomes
By the end of the lecture, the students will be able to:

1- Identify essentials before and during history taking

2- Recognize value of history taking

3- Describe items of full history taking

4- Know how to take thorough detailed history

Case scenario
A male patient named Ahmed Elsayed, 59

years old, from Mansoura, married 35 years

ago. He has 5 offsprings, the youngest is 16

years old . He works as a teacher and has no

special habits of medical importance. He has

a family history of Diabetes.

Learning outcome 1

Essentials before and during history taking

•
Essentials before History taking
Gain the patient confidence by few nice jests

• Understand the personality, culture level &

emotional state of the patient.

 Essentials during History taking
• Let the patient explain his complaint first in his own
words

• Ask the patient to explain clearly any vague words or

expressions

• Questioning may be

Neutral questions
Simple direct questions
Leading questions
Learning outcome 2

Value of history taking

 Value of history taking
• Some diseases may be diagnosed largely by history

taking as (anginal pain, migraine headache, GERD

“Gastroesophageal Reflux Disease, …etc)

• Good history taking helps in examination & suspicion

of affected system.
 Value of history taking
• Good history taking helps to put the differential

diagnosis of the disease.

• Good history taking helps in restriction of the required

investigations.

• Good history taking helps in follow up of the patient

Learning outcome 3

Items of full history taking

History taking should fulfill

• Personal history

• Chief complaint

• History of present illness

• Past medical history

• Family history
 Components of the History

❖ The present complaint ❖ Past surgical

❖ The history of the present history
complaint ❖ Drug history
❖ Remaining questions of
abnormal system
❖ Immunizations
❖ Review of systems
❖ Past medical history
❖ Family history
❖ Social history &
habits
Is it time to make a provisional diagnosis?

• What is a diagnosis?
Differential diagnosis or working diagnosis

• Most likely why?

• Less likely why?
• Least likely why?
 4-Review of systems
• The Gastro-intestinal system
• The Respiratory system
• The Cardiovascular system
• The Urogenital system
• The Nervous system
• The Musculoskeletal system
Learning outcome 4

Know how to take thorough detailed history

I- Personal history
1. Name
2. Sex
3. Age
4. Occupation
5. Residence
6. Marital status
7. Special habits
A- Name

• Take the patient whole official name

• Value
Be familiar with the patient
Know the religion of the patient
Death certificates
 B-Sex

• Diseases common in • Diseases common in males

females COPD
Hypothyroidism IHD
SLE Carcinomas
Cholecystitis

N.B. SLE: systemic lupus erythmatosus, COPD: Chronic obstructive pulmonary

disease, IHD: ischemic heart disease.
 C- Age
• Diseases common in children
1. Hemophilia. 2. Acute leukemia 3.Poliomyelitis

• Diseases common in middle age

SLE

• Diseases common in old age

1. Carcinomas
2. Cerebral stroke
D- Occupation
• Medical personnel
1. Obesity 2. IHD 3. HCV

• Radiation exposure

1. Malignancy 2. Sterility

• Lead workers (Battery and paint factories)

1. Anemia 2. Peripheral neuropathies

E- Residence

The site where the patient is living & also the site
of birth (endemic area or near a highly polluted
environment, etc.)
 F- Marital status
Single
Married
Divorced
Widow

• Ask about duration of marriage, has children or not,

their number & the age of the youngest.
G- Special habits

• Smoking

• Alcohol drinking

• Drug addiction
 II- Chief complaint
• In patient own words in one sentence

• N.B: don’t use medical terms

• Example: shortness of breath (don’t say Dyspnea )

……days, weeks, months ago

 III- History of present illness

• Analysis of symptoms

• Other symptoms related to the same system should

be said even positive or negative

• Symptoms of other systems

• Arrange symptoms chronologically

 1-Present complaint
• In patient’s own words with duration.
• “What are you complaining of?”
• “What is the problem?”
• “What is the matter?”
 2-History of the present complaint

EXAMPLE: ABDOMINAL PAIN

• Site • Radiation
• Time and mode of onset • Progression/end
• Nature • Relieving factors
• Duration • Exacerbating factors
• Severity • Cause
 Review of systems
• The Gastro-intestinal system
• The Respiratory system
• The Cardiovascular system
• The Urogenital system
• The Nervous system
• The Musculoskeletal system
Gastro-intestinal system

• Appetite • Heartburn
• Diet • Vomiting
• Weight • Haematemesis
• Teeth and taste • Abdominal PAIN
• Swallowing • Abdominal distension
• Regurgitation • Defecation
• Fatulance • Change of color of skin
 The Respiratory system
• Cough
• Sputum
• Haemoptysis
• Dyspnoea
• Orthopnoea
• Chest pain
 The Cardiovascular system
• CHEST PAIN
• Dyspnoea
• Orthopnoea
• Palpitations
• Cough and sputum
• Dizziness and headache
• Ankle swelling
• Peripheral vascular symptoms
The Urogenital system

• Scrotum and
• Pain
urethra
• Oedema
• Thirst
• Menstruation
• Micturition • Pregnancies
• Urine • Breasts
• Secondary sex
characteristics
 The Nervous system
• Mental state
• Conscious level
• Fits
• TIAS= transient ischemic attacks
• Loss of sensations
• Paraesthesiae (pins and needles)
The musculoskeletal system
• Pain
• Swelling
• Limitation of movements of any joint
Diagnosis
• Any diagnosis consists of
Anatomical part + Pathological part
Examples:
• Breast cancer
• Peptic ulcer
• Fracture femur
 IV- Past medical history

• Similar condition • Trauma

• Drug intake • Operations

• Allergy • Blood transfusion

• Infection • Traveling abroad

• Immunization
 Past medical history
• Any hospitalization
• TB = Tuberculosis
• DM = Diabetes mellitus
• Asthma
• Rheumatic fever
• Contact with patients
with hepatitis or aids
 Past surgical history
• Previous operations
• Blood transfusion
• Any complications with anesthesia
• Bleeding tendencies
 Drug history
• Steroids
• Insulin
• Antihypertensive drugs
• Hormone replacement therapy
 8-Immunizations
• DPT = diphtheria, pertussus, tetanus
• Measles
• Mumps
• Rubella
• Poliomyelitis
• TB
• Smallpox
• Typhoid
V- Family history

• Consanguinity

• Similar condition

• Other diseases
Family History
• Genetic diseases
• Sickle cell anemia, cystic fibrosis
• Familial diseases
• Type 2 diabetes, breast cancer, what else?
• Psychiatric diseases
• Heriditary
• Affect patient’s psychosocial environment
• Contagious or Toxic
• Lead poisoning, influenza
 Summary and wrap up
• Good history taking helps in examination, suspicion of
affected system and perform differential diagnosis

• There are many factors which are essential to be fulfilled

during and before history taking.

• History taking must fulfill 5 items ( personal history , chief

complaint , history of present illness , past medical
history and family history )
Questions:
1- Enumerate 4 Diseases can be diagnosed by
History talking:
• A- …………………………………………….
• B- …………………………………………….
• C- …………………………………………….
• D- …………………………………………….
Questions:
2- All the following are items for valid history taking
except:
• A- Sphygmomanometer use for blood pressure
measurement
• B- Personal Information
• C- Questioning about the offspring
• D- Writing the previous surgical operations done.
Questions:
3- The following are diseases common in female
except:
• A- Hypothyrodism
• B- SLE
• C- Cholecystitis
• D- COPD
Questions:
4- he following are diseases common in males
except:
• A- COPD
• B- IHD
• C- Carcinomas
• D- Hypothyroidism
Questions:
5- The following are diseases common in children
Except:
• A- Carcinomas
• B- Hemophilia
• C- Acute Leukemia
• D- Poliomyelitis
Questions:
6- The following can be gastro-intestinal symptoms
except:
• A- Heartburn
• B- Abdominal Pain
• C- Vomiting
• D-Orthopnea
Questions:
7- complaint of the patient should be written in
medical terms:
• A- True
• B- False
Questions:
8- Consanguinity may lead to several genetic
disorders:
• A- True
• B- False
Questions:
9- Chest pain may be a symptom for a cardiovascular
system disorders::
• A- True
• B- False
Questions:
10- Peripheral Neuropathies is a common disease in
workers with direct contact with lead:
• A- True
• B- False
Thank you