MEDICAL HISTORY
TAKING
Introduction
• Medical history is a structured assessment conducted to generate a
comprehensive picture of a patient’s health and health problems.
• It includes a review of:
• The patient’s current and previous health problems
• The patient’s health in general
• Factors that might affect the patient’s health and their response to prevention or
treatment of health problems e.g. risk factors to certain diseases
• Their family’s health
• Medical history taking is also known as ‘medical clerking’ and is essentially the
story (history) of the patient’s illness to date.
Importance of medical history
• Medical history, together with information from physical
examination and any investigations and tests should
provide all the information needed to make a diagnosis.
Important considerations: Dos
Important considerations: don’ts
Structure of the medical history
• During ‘clerking’ a fairly standard series of questions are asked
• This, together with investigations and results relating to their physical
examination are recorded in the notes.
• Notes written by medical doctors follow a similar format as outlined in the
subsequent slides
Biodata
• This is the information that is related to the patient identity
• The clinician notes the patient’s:
• Name
• Age
• Gender
• Marital status
• Occupation
Chief complaint
• ‘Complaining of ’ (C/O) or ‘presenting complaint’:
• This is a statement of what symptoms or problems have lead to the
patient’s admission or attendance
• Ideally it should be stated using the patient’s own words.
History of the present illness (HPI)
• This section provides more detail about the symptoms
• The following information is noted:
• Body location
• Quality and severity
• Chronology, including when it began, mode of onset, ending, duration, frequency
• Setting (the circumstances under which symptoms appear)
• Aggravating and alleviating factors
• Effect on normal activities
• Previous history of such symptoms
• The information should be in chronologic order, including diagnostic tests
done prior to admission.
Past medical history (PMH)
• This is to gather information about the person’s past illnesses and treatment
• It includes the following:
• Previous hospital admission
• Past surgical operations
• Major illnesses e.g. diabetes mellitus, asthma, heart disease, rheumatic fever
• Accidents and injuries
• Also includes drug history which describes :
• Any drugstaken/ stopped recently.
• Frequently used over-the-counter and herbal medicines.
• ADRs and allergies .
Past medical history(cont’d)
Importance of drug history
• Information on drug history is important because:
• Medication may be the cause of the presenting complaint
• Current medications may preclude the use of other medications
• If the patient is admitted to hospital , they may need to continue with
current medication(s)
• It provides an opportunity to review the need for taking the medication(s)
and to find out whether the person is actually taking them
• The patient may be suffering from side effects
Family history
• Significant information about the medical history of close family members is
noted.
• Whether parents and siblings are alive and well (A&W).
• Whether anyone in the family has a medical problem related to the
presenting complaint?
• If close family members have died, at what age and what was the cause of
death?
Social history
• This section documents factors in the person’s lifestyle, environment and personal
habits which can put them at risk of illnesses or have a bearing on the current illness.
• It also provides an opportunity on how the person maintains their health (e.g.
immunization, prophylactic drugs)and to consider whether there is need for primary
or secondary prevention
• Primary prevention is the prevention of disease e.g. through health education and
immunisation
• Secondary prevention is the prevention of effects of disease e.g. by early treatment or
prevention of worsening of the disease e.g. by removing causative agents (cessation of
smoking and losing weight after an attack of angina)
Social history (cont’d)
• Information gathered includes:
• The relevant details of the patient’s occupation, marital status and children
, religion and education
• Alcohol, smoking and recreational drug use
• HIV risk factors
• Housing
• Social or financial problems
• NB: Certain aspects of social history can be private and some patients
may find this intrusive. It is important to be mindful of this and maintain
a non-judgemental attitude
Review of systems
• On examination (O/E) — this is a general comment about what the patient
looks like (e.g. pale, sweaty, or short of breath (SOB)).
• The doctor examines each body system in turn, recording what they have
found by looking, listening, and feeling.
• They concentrate on any systems that are most relevant to the symptoms
described by the patient (e.g. if the patient has complained of chest pain,
the cardiovascular system (CVS) and respiratory system (Resp) are most
relevant).
Review of body systems
• The following body systems are usually covered:CVS, Resp,
gastrointestinal system (GI, GIT or abdo), central nervous system
(CNS), peripheral nervous system (PNS), bones and joints (ortho)
Checklist for review of systems
System Description
General Weight loss, weight gain, fatigue, weakness, appetite, fever, chills, night sweats
Skin Rashes, pruritus, bruising, dryness, sunburns and other lesions
Head Trauma, headache, tenderness, dizziness, syncope
Eyes Vision, changes in the visual field, glasses, last prescription change, photophobia, blurring, diplopia,
spots or floaters, inflammation, discharge, dry eyes, excessive tearing, history of cataracts or glaucoma
Ears Hearing changes, tinnitus, pain, discharge, vertigo, history of ear infections
Nose Sinus problems, epistaxis, obstruction, polyps, changes in or loss of sense of smell
Throat Bleeding gums; dental history (last check-up, etc.); ulcerations or other lesions on tongue, gums, buccal
mucosa
Respiratory Chest pain; dyspnoea; cough; amount and colour of sputum; haemoptysis; history of pneumonia,
influenza, pneumococcal vaccinations
Cardiovascular Chest pain, orthopnoea, dyspnoea on exertion, paroxysmal nocturnal dyspnoea,murmurs, peripheral
edema, palpitations
Gastrointestinal Dysphagia, heartburn, nausea, vomiting, hematemesis, indigestion, abdominal pain, diarrhea,
constipation, melena (hematochezia), hemorrhoids, change in stool color, jaundice, fatty food
intolerance
Checklist for review of systems(cont’d)
System Description
Gynaecological Gravida/para/abortions; age at menarche; last menstrual period (frequency, duration, flow);
dysmenorrhea; spotting; menopause; contraception; sexual history, including history of STDs, number
of partners, sexual orientation
Genitourinary Frequency, urgency, hesitancy; dysuria; haematuria; polyuria; nocturia; incontinence; discharge;
sterility; impotence; polyuria; polydipsia; change in urinary stream; and sexual history, number of
partners, sexual orientation, and history of STDs
Endocrine Polyuria, polydipsia, polyphagia, temperature intolerance, glycosuria, hormone therapy, changes in
hair or skin texture, menstrual abnormalities
Musculoskeletal Inflammation, redness, tenderness, limitations in ROM, back pain, musculoskeletal trauma, gout
Peripheral Varicose veins, intermittent claudication, history of thrombophlebitis
vascular
Hematological Anaemia, bleeding tendency, easy bruising, lymphadenopathy
Neuropsychiatric Syncope; seizures; weakness; coordination problems; alterations in sensations,memory, mood, sleep
pattern; emotional disturbances; drug and alcohol problems
Using medical history information
• After history taking, the clinician performs a physical examination.
• This information is used together to come up with an ‘impression’ i.e. a diagnosis.
• A plan of action is then drawn up which may include:
• Admission to the ward
• Initiation of medications, continuing or cessation of existing medications
• Follow-up plan
• Investigations- laboratory tests, imaging e.g. ultrasound, CT scan, MRI
• Blood grouping and cross matching for transfusion
• Further review e.g. by a specialist
• Referral to a higher level hospital
• Food and fluid instructions
• Monitoring plan
