The purpose of history taking and physical
examination as stated earlier is to collect information from the patient,
examine the patient, and to understand the patient's
The traditional history taking has several parts, each
with a specific purpose. In order to achieve maximum success, the medical
history must be accurate, concise, and systematic. Following is a STANDARD
outline of the different components of history taking in sequential order.
The introductory materials in the health history consist
of collecting the following information from the patient:
1.1. Data Collection
The following information is obtained in all patients
to gain a basic understanding of the patient:
|Date of birth:
1.2. Chief Complaints
Described in the patient's own words the reason for
e.g.; "I have a toothache" or "I
need routine cleaning" or "I need a root canal"
1.3. Present History
List in clear chronological order, the details of the
problem or problems for which the patient is seeking care. You will determine
by interrogation the time line of:
- When did the patient's problem(s) begin?
- Where did the problem begin?
- What kinds of symptoms did the patient experience?
- Has the patient taken any treatment for the problem?
- Has the treatment had any effect on the patient or has the
treatment not improved or altered the patient's condition?
- It is also important to determine if the problem(s) have
affected the patient's lifestyle. that is, have the symptoms experienced
because of the problem(s) caused any incapacities?
1.4. Past History
Gives you an insight about the health status of the
patient up until now. Check with the patient for the presence or absence of the
following conditions by eliciting the symptoms and signs associated
with those conditions:
- Angina, Myocardial Infarction, TIA (Transient Ischemic
Attacks), CVA (Cerebro Vascular Attacks /stroke), Hypertension, rheumatic heart
disease, Asthma, tuberculosis, bronchitis, sinusitis, chronic obstructive
pulmonary disease (COPD).
- Determine the list of current
medications that the patient is taking:
- Over-The-Counter (OTC) medications
Also determine if the patient is currently on steroids or has the patient been prescribed any
corticosteroid preparations within the past two
years. Check if the patient has any known allergies
to any drugs like NSAIDs, aspirin, codeine, morphine, penicillin, sulpha, or
any local anesthetics.
- Common disorders to be ruled out (in
the medical lingo, it means to establish that a disease is not present) in the
patient are: diabetes, hyperthyroidism, hypothyroidism, adrenal
disorders--Addison's disease or Cushing's
Fits or faints:
- Rule out different kinds of seizures in the
patient--grand mal epilepsy, petit mal epilepsy, temporal lobe or
psychomotor epilepsy, or localized motor seizures.
- Rule out oral ulcerations, esophagitis, gastritis,
peptic ulcerations, Crohn's disease, coeliac disease, ulcerative colitis,
polyps, hemorrhoids, etc.
- Determine the cause or causes for admission. Did the
patient have any history of accidents or injuries? Was the patient given any
anesthesia--local/general? Were there any complications during the
hospital admission due to the anesthesia or the medical/surgical condition?
Was the patient given any blood transfusion during hospitalization?
- Check for Infectious diseases of
childhood: like measles, mumps, chicken pox, strep pharyngitis,
rheumatic fever, scarlet fever. Check for Infectious disease of
adulthood: STDs (sexually transmitted diseases), hepatitis (especially
viral hepatitis), HIV infection, infectious mononucleosis
- Lupus, Sj绎grens syndrome, rheumatoid arthritis,
polyarthritis nodosa, etc.
Jaundice or liver disease:
- Has the patient developed jaundice due to viral
hepatitis or alcoholic hepatitis, gall stones, etc.? Is there any history of
gall bladder dysfunction? Is there any indication of improper liver
- Is there any indication of kidney dysfunction or renal
stones, urinary tract infections, or renal failure or renal
- Likelihood of pregnancy
- Osteoporosis and other causes of impaired bone
metabolism; Paget's disease; osteoarthritis; rheumatoid arthritis;
psoriatic arthritis; gout; muscular dystrophies; polymyositis; myasthenia
- Cranial nerve disorders; headaches and facial pains,
including migraine; multiple sclerosis; motor neuron disease; TIA (transient
ischemic attacks) or CVA (cerebrovascular accidents) associated neurological
deficits; Parkinson's disease; peripheral neuropathies
Obstetric and gynecological disorders:
- Is there any significant condition or disease(s) that
can lead to bleeding or anemia; any tumors needing chemotherapy or
- Personality disorders, neuroses, anxiety, phobias,
hysteria, psychoses, schizophrenia, PTSD (post traumatic stress
- Radiation therapy
- Lichen planus, phemphigus, herpes simplex, herpes
zoster, eczema, unhealed skin lesions or urticaria (itching of the
- Tetanus immunization/hepatitis
- Domestic violence; elder abuse; child
- Wound healing
1.5. Personal History
In this part of the history one tries to get an
insight into the patient's lifestyle, occupation, and habits:
- In the lifestyle component an attempt is made to
understand what constitutes a typical day for the patient. What does the
patient do for recreation, relaxation, etc.?
- What kind of job does the patient have? Are there any
job-related toxic exposures that exist?
- Is there any history of alcohol intake? How much?
Coffee/tea intake? How much? Any history of diarrhea, vomiting?
- Is there any history of smoking cigarettes or using
"recreational" drugs like marijuana, cocaine, amphetamines,
- Has the patient ever used IV drugs? Has he ever swapped
- Has the patient been exposed to any infectious diseases or
sexually transmitted diseases (STDs)?
- Does the patient use any herbal medications or
over-the-counter medications like diet pills, birth control pills, laxatives,
analgesics (aspirin, acetaminophen, etc.: pain killers), or cough/cold
1.6. Family History
After the patient's medical history has been
explored, it is important to find out about the health of the immediate members
of the family:
- One has to determine if certain common diseases run in the
family, i.e., does a familial pattern exist
- In this part of the history, you have to determine the age
and health of the patient's parents, siblings and children
- If any member is deceased, the age and cause of death is
- Common diseases, with a strong hereditary component or
tendency for family clustering, are sought, e.g., coronary artery disease(
CAD), heart disease, diabetes mellitus (DM), hypertension (Htn), stroke (CVA),
asthma, allergies, arthritis, anemia, cancer, kidney disease or psychiatric
1.7. Review of Systems (ROS)
In this portion of the history, all organ systems not
already discussed during the interview are systematically reviewed. ROS is a
final methodical inquiry, prior to physical examination. It provides a thorough
search for further, as yet unestablished, disease processes in the patient. If
the patient has failed to mention symptoms, this process of ROS would remind
the patient at this point. Also, if you have unknowingly omitted certain points
of inquiry, now would be the time to establish those.
Following are the topics to be reviewed for
each organ system:
- Any history of recent weight change
- Any history of anorexia (loss of appetite), weakness,
fatigue, fever, chills, insomnia, irritability or night sweats
- Any history of skin rashes--acute or chronic, is it
unilateral or bilateral
- Any history of allergic skin rashes
- Any itching of the skin
- Any history of unhealed lesions (probably due to:
diabetes; poor diet; steroids and other causes of decreased immunity,
- Any history of bruising, bleeding
- Any history of headaches
- Loss of consciousness (may be due to cardiovascular,
neurologic causes, anxiety, metabolic causes, etc.)
- History of seizures. Are they general (with or without
loss of consciousness) or focal? Are there any motor movements?
- Is there any history of head injury?
- Check for vision, history of glaucoma ( could cause pain
in the eyes), redness, irritation, halos (seeing a white ring around a light
source), blurred vision
- Any irritation of the eyes, excessive tearing, which
can be associated with frequent allergic symptoms?
- Any recent change in hearing
- Any pain in the ears or ringing in the ears (tinnitus)?
- Any history of vertigo (dizziness)?
1.7.6. Lymph Glands
- Any history of lymph glandular enlargement in the neck
or elsewhere? Are they tender/painless? How were they first
- Are they freely mobile or are they adherent to
the underlying tissues?
1.7.7. Respiratory System
- History of frequent sinus infections
- Postnasal drip
- Cough (with/without expectoration)
- Color of sputum, when present
- History of sore throat
- History of shortness of breath on exertion or at
- Any history of wheezing (may be due to asthma,
- Hemoptysis (blood in the sputum): may be due to dental
causes; lung causes like bronchitis, tuberculosis; cardiac causes like mitral
stenosis or CHF (congestive heart failure). Determine if it is a blood-tinged
sputum or there is frank blood in the sputum.
- Any history of bronchitis, asthma, pneumonia, emphysema,
1.7.8. Cardiovascular System
- History of chest pain or discomfort
- History of palpitations: were the palpitations
associated with syncope (loss of consciousness)?
- History of either hypertension or hypotension
- Does the patient experience any paroxysmal nocturnal
dyspnea (shortness of breath during sleep, in the middle of the night)? Is
there any SOB in relation to exercise or exertion?
- Any history of orthopnea (shortness of breath when lying
flat in bed)? Does the patient use more than one pillow to sleep? Has this
always been the case, or has the patient recently started using more pillows?
- History of edema (site of edema--legs, face, etc.)
- Any history of leg pains, cramps? Are they relieved by
rest (this is suggestive of intermittent claudication) or is it unremitting?
(this is muscular)
- Any history of murmur(s), rheumatic fever, varicose
- Any history of hypercholesterolemia, gout, excessive
smoking, i.e., conditions which can lead to or worsen heart disease
1.7.9. Gastrointestinal System
- History of bleeding gums, oral ulcers or
- History of dysphagia (can the patient point out and
describe where the difficulty swallowing exists?)
- History of heartburn, indigestion, bloating, belching,
- History of nausea: is it related to food? Is it one of
the many symptoms due to GI (gastrointestinal) disease?
- Vomiting: is there any associated weight loss,
psychosocial factors, or are medications causing it?
- Hematemesis (vomiting blood). Ask for associated ulcer
history, food intolerance, abdominal pain or discomfort
- Jaundice: is there a viral cause, gallstones, associated
- History of diarrhea/constipation
- Any change in color of stools
- History of polyuria (excessive urination) due to
diabetes, renal disease, unknown cause, etc. Check if this has been a recent
- History of nocturia (getting up at night to go to the
bathroom). Is this a recent change?
- History of dysuria (painful urination). If it is
because of urinary tract infection (UTI), the patient will experience frequency
and urgency in addition to dysuria. STD will also be associated with similar
symptoms (was treatment for STD completed?)
- History of renal stones, pain in the loins, frequent
1.7.11. Menstrual History
- Date of LMP (last menstrual period). Always precede this
question by informing the patient that she has to get x-rays done, so you need
to know if she is pregnant; thus, the need to know her LMP
- Any history of menorrhagia (heavy periods)
- History of use of birth control pills
1.7.12. Musculoskeletal System
- History of joint pains--determine location: is it
acute or chronic? Unilateral or bilateral? More in the morning or evening? Are
there associated systemic symptoms?
- Any history of rheumatoid arthritis, osteoarthritis,
1.7.13. Endocrine System
- History of symptoms due to diabetes, i.e., polyuria,
polydypsia, polyphagia1, weight change
- History of thyroid symptoms: heat/cold intolerance,
increased/decreased heart rate, goiter, etc.
- History of adrenal symptoms: weight change, easy
bruising, hypertension, etc.
1 Polyuria -- excessive urination;
polydypsia -- excessive thirst; polyphagia -- excessive
1.7.14. Nervous System
- History of stroke, CVA, TIA
- History of muscle weakness, involuntary movements: they
may be tremors, seizures, or anxiety, etc.
- History of sensory loss of any kind: anesthesia,
paresthesias, or hyperesthesias2
- Is there any change in memory, especially recent change.
2 Anesthesia ??/span> no sensation; paresthesia ??altered sensation, commonly a pins and needles
sensation; hyperesthesia ??/span> increased
1.8. Concluding History
It is important at this point to collect the relevant
data about the patient (all positive findings) and construct a logical
framework of the case.