History Taking in Medicine

History Taking

• Confidentiality and respect for patient privacy are essential
• Effective questioning techniques include:
  • Simple and clear questions
  • Avoiding medical terms
  • Open, leading, and direct questions
  • Summarizing questions

Complete History Taking

Personal History

• Full name
• Age
• Sex
• Address
• Marital status
• Occupation

Chief Complaint

• The main reason for visiting a physician
• Recorded in the patient's own words

Present History

• Elaboration on the chief complaint in detail
• Associated symptoms in chronological order
• Negative information included to exclude other possibilities
• System review:
  • Respiratory system
  • Cardiovascular system
  • Gastrointestinal system
  • General system

Past History

• Medical problems (e.g., heart attack, asthma, diabetes)
• Past surgical/operation history
• History of trauma/accidents

Family History

• Previous similar illnesses in the family (e.g., hereditary diseases)

Psycho-Social History

• Smoking history
• Drinking history
• Occupation
• Education background
• History of psychiatric disease

Other Relevant History

• Gynaecological/obstetric history (if female)
• Immunization history (if a small child)
• Travel and sexual history (if STI or infectious disease)

Patient-Centred Method

• Greater patient satisfaction
• Greater doctor satisfaction
• Better patient adherence
• Improved patient outcomes
• Higher quality of self-reporting
• Fewer malpractice claims
• Positive impact on healthcare utilization costs
• Greater physician detection

Clinical Approach

History

• Relevant information gained from the patient

Examination

• General examination including vital signs

Investigation

• Only relevant investigations requested

Diagnosis

• Based on previous steps

Comprehensive Management

• Including health education, non-pharmacological and pharmacological management

Follow-up

• To assess patient compliance and degree of improvement

Importance of History Taking

• Essential skill for decision making
• Useful for making a diagnosis before performing a physical examination

Acute Otitis Media (AOM)

• Management:
  • Watching and waiting for children with non-severe AOM
  • Antibiotics provided for severe cases or worsening symptoms
  • Referral for severe systemic infection, recurrent AOM, or failure to improve

Hypertension

• Persistent elevation of blood pressure:
  • ≥ 140 systolic and ≥ 90 diastolic
  • Categories of BP in adults:
    • Normal BP
    • Elevated BP
    • Hypertension (stage 1 and 2)
    • Resistant hypertension
    • Hypertensive urgency
    • Hypertensive emergency
• Called a silent killer due to its contribution to cardiovascular risk