The Comprehensive Adult

Health History Taking

For C-I Students
“The proper exercise of the five senses is
often far more valuable than a handful of
laboratory reports and radiographs.”
Lennert Norrlin
Vasteras, sweden
 Order of case recording
1.Identification
2.Previous admissions
3.Chief complaints
4.History of the present illness
5.Past medical history
6.Personal and social history
7.Family history
8. Functional inquiry (system review)
9.Physical examination
10.Summary:
(a) Subjective
(b) Objective
11.Differential diagnosis
12.Discussion of differential diagnosis
13.Investigation
14.Final diagnostic impression or final
diagnosis
15.Treatment
 History Taking
General comments
• Be confident and quietly friendly
• Greet the patient
• State your name and that you are a student doctor
helping staff care for patients
• Explain that you wish to ask the patient questions to find
out what happened to him/her
• Let the patient tell his/her story in his/her own words as
much as possible
• Try to conduct a conversation rather than an
interrogation
• Don’t ask leading questions
 Identification
• Date and Time of History
• Identifying Data
-Name
-Age
-Gender
-Marital status
-Occupation
-Religion
-Ethnicity
-Address
• Source of referral
• Source of history
• Reliability
• Previous admission
 Chief Complaint(s)
• Are those symptoms which prompted the patient
to seek medical advice
• Should be simple, brief
• Duration of symptom should be clearly
described
• If there are more than one complaint , they
should be listed in order of occurrence
• Make every attempt to quote the patient’s own
words
 History of the Present Illness
• In obtaining the HPI , follow in chronological order
1. Date of onset (He/She was relatively healthy until….)
2. Mode of onset, course and duration
3. Character and location
4. Exacerbation and remission
5. Effect of treatment
6. “pertinent positives” and “pertinent negatives”
7. Color ,strength and weight
• Always remember, the data flows spontaneously from
the patient, but the task of organization is yours.
 Past Medical History
• Childhood illnesses
• Adult Illnesses
- Medical (such as diabetes, hypertension…)
- Surgical (include dates, indications, and types of
operations);
- Obstetric/gynecologic (relate obstetric history, menstrual
history, birth control, and sexual function);
- Psychiatric (include dates, diagnoses, hospitalizations,
and treatments).
• screening test
 Personal and Social History
• Early development - place of birth and early
homes,childhood development,health and
activities,social and economic status
• Education-school history,achievement and
failures
• Social activities -recreation and other
activities
• Work records -age begun ,type and number
of job,industrial hazards and exposure
• Environment-living condition
• Habits-dietary, alcohol, drugs ,tobacco
 Family History
• Father and mother - the age and health, or age and
cause of death,
• Siblings - list with ages ,health (if dead mention cause of
death).
• Review each of the following conditions and
record if they are present or absent in the
family:
- hypertension, coronary artery disease, elevated
cholesterol levels, stroke, diabetes, thyroid or renal disease,
cancer (specify type), arthritis, tuberculosis, asthma or lung
disease ,headache, seizure disorder, mental illness, suicide,
alcohol or drug addiction ,and allergies.
 Review of Systems
• Head, Eyes, Ears, Nose, Throat (HEENT).
• Head: Headache, head injury, dizziness, lightheadedness.
• Eyes: Disturbance in vision, pain, redness, excessive
tearing, double vision, blurred vision, photophobia, flashing
lights, itching.
• Ears: Hearing, tinnitus, vertigo, earaches, discharge. If
hearing is decreased, use or nonuse of hearing aids.
• Nose and sinuses: nasal stuffiness, discharge, or itching,
nosebleeds.
• Throat (or mouth and pharynx): Condition of teeth,
gums, bleeding gums, sore tongue, dry mouth, frequent sore
throats, hoarseness.
 . Glands -Neck. Lumps, “swollen glands,” goiter,
heat or cold intolerance, excessive sweating, pain,
or stiffness in the neck.
- Breasts. Lumps, pain or discomfort,
nipple discharge, self-examination practices.
• Respiratory. Cough, sputum (color, quantity,color,
odour), hemoptysis,dyspnea, wheezing, pleurisy
(chest pain)
• Cardiovascular. high blood pressure, chest pain
or discomfort (with character ,location radiation),
palpitations, dyspnea, orthopnea (number of pillows
required), paroxysmal nocturnal dyspnea, leg
swelling ,dyspnea (degree of exercise tolerance)
• Gastrointestinal. Pain on swallowing, heartburn, appetite,
nausea, vomiting, change in bowel habits, rectal bleeding or
black or tarry stools, constipation, diarrhea, abdominal pain,
food intolerance, excessive belching or passing of gas,
Jaundice(yellowish discoloration of the eye)
• Genito Urinary. Frequency of urination, polyuria, nocturia,
urgency, burning or pain on urination,change in urine color(
hematuria), kidney stones, incontinence;in males, reduced
caliber or force of the urinary stream, hesitancy,dribbling.
• Male: discharge from or sores on the penis, testicular pain
or masses, history of sexually transmitted diseases and
their treatments .Sexual habits, interest, function,
satisfaction, condom use, and problems.
Female: Age at menarche; regularity, frequency, and duration of periods;
amount of bleeding,bleeding between periods or after intercourse, last
menstrual period; Dysmenorrhea (pain during menustratuon),
premenstrual tension; age at menopause, menopausal
symptoms,postmenopausal bleeding, Vaginal discharge, itching, sores,
lumps, sexually transmitted diseases and treatments. Number of
pregnancies, number and type of deliveries, number of abortions
(spontaneous and induced); complications of pregnancy; birth control
methods. Sexual habits, interest, function, satisfaction, any
problems,including dyspareunia.
• Integumentry (skin , hair and nails). dry or moist skin ,rashes,
ulcers, hair distribution and pigmentary change ,change in finger nails

• Musculoskeletal. Muscle or joint pains, swelling, and back pain. If

present, describe location of affected joints or muscles, presence of any
swelling, redness, pain, stiffness, weakness, or limitation of motion or
activity; include timing of symptoms (for example, morning or evening),
duration, and any history of trauma. Intermittent claudication, leg cramps

• Central nervous system. Fainting, blackouts, poor memory ,seizures,

weakness, numbness or loss of sensation, tingling or “pins and needles
,involuntary movements.
“Clinical diagnosis is an art, and the
mastery of an art has no end ; you can
always be a better diagnostician.”
Logan Clendening
University of
Kansas,U.S.A````