Case history taking

Special situations

• Infants under 5yrs; parent is interviewed
• Unconscious patients
• Under drugs effect
• Shying patients
• Emergency situation

In Emergency

• Fast the procedure but do not ignore it
• In case of emergency, obtain information from patient and/or bystanders

Classical history taking

Personal data

• Name:
• Full, accurate
• Communicate with patient
• Medico-legal aspects
• Age:
• Date of birth is better
• Growth and development is noted
• Certain diseases correlated with age
• Management techniques according to age

• Sex:
• Some diseases shows sex predilection
• Ethics & religious consideration
• Marital status: Infertility, pregnant…
• Contacts:
• Address: endemic diseases, follow up visits
• Phone
• Nearest kin

Personal data

Occupation: Socio economic status

• Occupation: Socio economic status
• Race: Some certain diseases
• Religious: Certain considerations
• Date & type of admission
• Hospital number

Personal data

Chief Complaint

• First symptoms that caused patient to seek medical advice
• Often:
• Pain
• Bleeding
• Abnormal function
• Observation of a lump

Many complaints

• Always record patient’s own words
• In order of severity
• In chronological order

Present History

• Def.: Details of symptoms & their progress
• Should be well organized, clear, detailed

It is important to get right back to the beginning of the problem

Present History

• Etiology (predisposing factors)
• Classical course of disease
• Any complications
• Loco-regional effect
• Systemic effect

Present history

• Negative information should be included if they contribute to the diagnosis or help exclude other possibilities

Past & medical history

Past & medical history

• Allergy & anemia
• Bleeding disorders
• Cardio respiratory disorders
• Drug history
• Endocrine disorders
• Fits & faints
• Gastrointestinal disorders
• Hospital admissions & surgeries
• Infections
• Jaundice & hepatic disease
• Kidney

Family history

Ask about health or cause of death of patient’s parents, grandparents, brothers and sisters

Previous similar illnesses in the family

Potential for hereditary diseases

Reproductive history

• Infertility of both sexes
• Gynecological causes of abdominal pain
• Pregnancy & lactation
• Also ask about:
• Contraceptive use
• Venereal disease

Habits

• Smoker
• Athletics
• Appetite
• Alcohol
• Coffee
• Sexual

Sensitive Topics

• Alcohol or drug abuse
• Physical abuse or violence
• Sexual issues
• Psychiatric problems

Sensitive Questions Guidelines

• Respect patient privacy
• Be direct and firm
• Avoid confrontation
• Be nonjudgmental
• Use appropriate language
• Document carefully
• Use patient’s words as possible

Special Challenges

• Silence # overly talkative patients
• Patients with multiple symptoms
• Anxious patients
• Anger and hostility
• Crying & depression
• Confusing behavior or histories
• Limited intelligence
• Developmental disabilities

Barriers to Communication

• May result from:
• Social or cultural differences
• Sight, speech, or hearing impairments
• Attempt to find assistance to aid in communication

Patient encourages

Let patient continue talking

• FACILITATION

“Tell me more about it”

“ Please go on”

“I’m interested to hear about it “

• Rocking: “Yes, Uh huh, umm, I see”
• Repeating: ”It usually happens at night?”

Finally

• Explain to the patients what is going on
• Encourage patient to ask questions
• Next plain
• Thank the patients
• Date & signature

Do not

• False quick diagnosis
• Malignancy
• Debilitating disease
• False reassurance
• May be tempting
• Avoid early assurance or “over reassurance”
• Unless it can be provided with confidence