Internal Medicine 1

History Taking
Dra Jocelyn T. Cordero
28 June 2017

COMPREHENSIVE vs. FOCUSED ASSESMENT

happening, for you to be able to have a working
Comprehensive Assessment (you have to interview all
diagnosis)
of the part of history; all aspects of the general data, of
3. Establish and testing a set of explanatory
the personal, social)
hypotheses (having a working diagnosis, will
For patients you are seeing for the first time in prevent you from doing unnecessary diagnostic
the office or hospital tests, you only request for the pertinent tests)
Which includes all the elements of the health
history and the complete physical examination THE ADULT HEALTH HISTORY
Focused Assessment (for follow-up, e.g: if the
symptom decreases)
Is appropriate, particularly for patients you know
well who are returning for routine office care or
for patients with specific urgent care concerns
like sore throat or knee pain.

ESSENTIAL ELEMENTS
Empathic listening
Ability to interview patients of all ages, moods,
and backgrounds (you should be able to adapt,
adjust base on the mood and age of the patient)
Techniques for examining the different body
systems
Process of clinical reasoning
STEPS OF CLINICAL REASONING
1. Identifying problem symptoms and abnormal
findings
2. Linking findings to an underlying process of
pathophysiology or psychopathology (you should
be able to explain why particular symptom is
Identifying and Source of the history (reliability of
source?)
Include the source of information
(relative or the patient himself)
Unconscious, psych patients- interview
the relative
Reliability of 75% is good enough
You will get about 90% reliability if the
patient is the source of information
(except special cases like psych..etc.)
Chief complaint(s)
The reason why the patient came to the
emergency room
Maximum number of chief complain - 2
complaints
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 If 3 or more complaints - it is already a
History of Present Illness
Present Illness
Past History
Family History
Personal and Social History
Review of (organ) systems
Going through all the organ system-
only question and answer
IDENTIFYING DATA
Name
Age
Gender
Religion
Occupation
Marital status
Citizenship
Source of history ideally the patient
Source of the referral (private physician,
hospital, insurance)
Date and Time of History
RELIABILITY
Memory (impaired memory such as patients with
Alzheimers Disease, dementia- decreases the
reliability of the data)
Trust (if the patient don't trust you, they will not
tell you everything or they will not admit having
(eg) Hepatitis B)
Mood (if patient is irritated)
CHIEF COMPLAINT
One or more symptom/ concerns causing the
patient to seek care
Patients own words
Do not use medical term, instead use
laymans term
eg. patient: naninilaw yung balat ko.
use yellowish discoloration of the skin
Make every attempt to quote the patients own
words. For example, My stomach hurts and I
feel awful. Sometimes patients have no specific
complaints. Report their goals instead. For
example, I have come for my regular check-up
or Ive been admitted for a thorough evaluation
of my heart.
PRESENT ILLNESS
Amplifies the CHIEF COMPLAINT
Narrative of how each symptoms developed
(CHRONOLOGY OF EVENTS)
e.g. chief complaint: is epigastric pain
History of the present illness: Two
weeks ago, patient had low grade fever,
then 7 days prior to consultation the
patient experience epigastric pain
Patients thoughts/feelings
Relevant portions of the Review of systems
May include history of smoking/alcohol intake,
medications, allergies which are relevant to the
present illness
Do not include the DATE, instead use the
number of days, weeks, or hours prior the
consultation
This section of the history is a complete, clear,
and chronologic account of the problems
prompting the patient to seek care. The narrative
should include the onset of the problem, the
setting in which it has developed, its
manifestations, and any treatments.
Pertinent positives and negatives from the
Review of Systems RELATED TO THE CHIEF
COMPLAINT
Risk factors (e.g. angina)
Current medications/supplements/
contraceptives (name, dosage, route frequency,
compliance)
SMOKING/ ALCOHOL/ ILLICIT DRUGS
Smoking
REPORTED IN PACK YEARS (computed); 1
pack= 20 sticks
Alcohol/ Drugs
Frequency
Pattern of use
Family history (ask family members)
What type (beer, wine)
Reactions, injuries, conflict in job/personal
relationships/legal problem
SEVEN ATTRIBUTES (PRESENT ILLNESS)
OLD CART
O= when is the onset
L= location of the of the problem (eg, epigastric,
hypogastric..)
D= duration of the problem
C= character
A= aggravating factors/relieving fators/
associate symptoms
R= radiation
T= timing (what would trigger the problem/ what
time does it occasionally occur?)
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PAST HISTORY
Childhood illnesses (mumps, measles, rubella,
chickenpox, rheumatic fever, polio congenital
illnesses)
Medical e.g. DM, HPN, asthma,
hepatitis, HIV, sexual practices (difficult
to ask especially if the patient is
married) (number and gender of
partners)
Surgical (state operation, indication,
exact/recalled date)
OB/Gyne (OB hx, menstrual hx,
contraception)
Psychiatric : illness and time frame,
diagnosis, hospitalization and
treatments
Adult illnesses
Lifestyle/environmental, (exposure to chemical,
if house is near to factory )
Health Maintenance
Screening tests (tuberculin test, pap
smear)
Immunizations (if patient has received
vaccines for tetanus, pertussis,
diphtheria, MMR, influenza, varicella,
hepa B, pneumococci, herpes zoster)
Asked for adult immunization ( hepa b,
flu vaccine, typhoid, pneumococcal)
FAMILY HISTROY
Familial/hereditary illnesses (review each of the
ff condition if they are absent or present in the
family)
HPN, DM, ASTHMA, CVA, SUDDEN
DEATH
< age of 40, ARTHRITIS, CA,
BLEEDING DISORDERS, CAD,
cholesterol, TB (more on
exposure within the family, not
hereditary), seizure disorder,
mental illness, alcohol/drug
addiction, allergies
Outline or diagram
Age/health or Age/Cause of death of parents,
siblings, grandparents
PERSONAL/ SOCIAL
Capture patients personality and interest,
sources of support, coping style and fears
Educational level, occupation level last year of
schooling
Current household
Personality, Personal interests
Lifestyle smoking, alcohol intake, usual diet,
exercise, supplements, caffeine
Stress factors (level of stress) (recent and long
term), spiritual beliefs
Safety measures
Important life experiences: job history, military
service, religious affiliation, spiritual beliefs, and
activities of daily living.
Alternative health care practices
REVIEW OF SYSTEMS
Importance: you are only noting for other
possible problems, if there is any, you need to
have a work up for that)
Going over all of the organ systems, question
and answer
Should come at the end of the interview and
questions that are related to the chief complaint
Sample of starting questions: how are your ears
and hearing? How about your lungs and
breathing? any trouble with your heart? How
about your digestion?
Presence or absence of common symptoms
related to each major body system
Uncover problems UNRELATED to the present
illness
List of questions to be asked/ check list of symptoms:
Did you ever experience:
nausea and vomiting
weight loss
weight gain
General
Weight, recent weight change,
weakness, fatigue and fever
Skin
Rashes, lumps, sores, itching, dryness,
changes in color, changes in size and
color of moles, changes in hair or nails.
HEENT
Head: dizziness, lightheadedness
Eyes: vision, contact lenses, excessive
tearing
Ears: hearing, tinnitus, vertigo, infection,
discharge
Nose and sinuses: nosebleed, sinus
trouble
Throat: bleeding gums, dentures
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 Neck problem and to diagnostic and
Swollen glands, goiter, lumps, stiffness therapeutic intervention
in neck
Breasts Differences between Subjective and Objective Data
Lumps, pain, discomfort, nipple Subjective
discharge What the patient tells you (Ex: Dr. I have a
Respiratory headache)
Cough, sputum, wheezing, chest pain The patients history
Cardiovascular Objective
Heart trouble, high blood pressure, Findings during physical examination
palpitations, heart murmurs Key skills for successful interviewing:
Gastrointestinal Observation
Trouble swallowing, heart burn, nausea, Communication
change in bowel habits, rectal bleeding Facilitation
Urinary
frequency of urination, polyuria, GETTING READY
hematuria, urgency, burning(pain during Self-reflection
urination) kidney stones, flank pain Reviewing the chart
Genital Setting goals for the interview
Hernia and testicular masses in male, Reviewing your clinical behavior and
age at menarche vaginal discharge and appearance
itching in females Adjusting the environment
Peripheral vascular Taking notes
Intermittent claudication; leg cramps;
varicose veins; past clots in the veins; Physician responsibilities:
swelling in calves, legs, or feet; color Setting expectations
change in fingertips or toes during cold Setting pace
weather; swelling with redness or Clarifying goals
tenderness.
Guiding the interview through smooth transitions
Musculoskeletal
Muscle or joint pain, stiffness, gout back STAGES
ache, if present describe location of Opening Stage
affected muscle or joints
Establish rapport, put the patient at ease, define
Psychiatric goals for the interview
Nervousness, tension, mood, Middle Stage
depression, memory change, suicide
Collect information relevant to goals of the
attempts
interview
Neurologic Closing Stage
Changes in mood, attention or speech,
Provide feedback, information, education &
judgment, headache, dizziness, vertigo
planning
Hematologic Primary tasks:
Anemia, easily bruising or bleeding, past
To establish rapport and help the patient feel as
transfusion
comfortable as possible
Endocrine
To define the purpose and scope of the
Thyroid trouble, heat or cold intolerance,
interview
excessive sweating and thirst
S-O-A-P
THE SEQUENCE
Subjective 1. Greeting the patient & establishing rapport
Gather history from patient or family
Greet the patient by name and introduce
Objective yourself, giving your name. If possible, shake
Conduct physical examination and hands.
testing
If this is the rst contact, explain your role,
Assessment including your status as a student and how you
Observation, analysis, and interpretation will be involved in the patients care.
of data
Using a title to address the patient (e.g., Mr.
Plan ONeil, Ms. Wu) is always best. Avoid rst
Describes the approach to the problem names unless you have specic permission from
but it must include patient response to a the patient.

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 Maintain condentiality. Let the patient decide if
visitors or family members should remain in the
room, and ask for the patients permission
before conducting the interview in front of them.
Attend to the patients comfort. Ask how he or
she is feeling and if you are coming at a
convenient time. Look for signs of discomfort:
frequent changes of position or facial
expressions that show pain or anxiety. Arranging
the bed may make the patient more comfortable.
Consider the best way to arrange the room.
Choose a distance that facilitates conversation
and good eye contact. Try to sit at eye level with
the patient. Move any physical barriers between
you and the patient, such as desks or bedside
tables, out of the way.
Give the patient your undivided attention. Spend
enough time on small talk to put the patient at
ease. If necessary, jot down short phrases,
specic dates, or words rather than trying to put
them into a nal format. Maintain good eye
contact, and whenever the patient is talking
about sensitive or disturbing material, put down
your pen.
2. Inviting the patients history
Begin with open-ended questions that allow full
freedom of response: Tell me more about.
Avoid questions that restrict the patient to a
minimally informative yes or no answer.
Listen to the patients answers without
interrupting.
Train yourself to follow the patients leads.
Use verbal and nonverbal cues that prompt
patients to recount their stories spontaneously.
Use continuers, especially at the outset, such as
nodding your head and using phrases such as
Uh huh, Go on, and I see. OTHER TASKS:
3. Establishing the agenda for the interview
Identify both your own and the patients issues
at the beginning of the encounter.
Focus the interview by asking the patient which
problem is most pressing: Do you have some
special concerns today? Which one are you
most concerned about?
Some patients may not have a specic
complaint or problem. It is still important to start
with the patients story.
4. Expanding & clarifying the patients history
Each symptom has attributes that must be
claried, including context, associations, and
chronology, especially for pain. It is critical to
understand fully every symptoms essential
characteristics. Always elicit the seven features
of every symptom
5. Generating & testing diagnostic hypothesis
Identifying the various attributes of the patients
symptoms and pursuing specic details are
fundamental to recognizing patterns of disease
and differentiating one disease from another.
6. Negotiating a plan
Learning about the disease and conceptualizing
the illness give you and the patient the basis for
planning further evaluation (physical
examination, laboratory tests, consultations,
etc.). Motivational interviewing techniques may
help the patient achieve desired behavior
changes
7. Planning for follow up and closing the interview
Make sure the patient fully understands the
plans you have developed together: We need to
stop now. Do you have any questions about
what weve covered?
Review future evaluation, treatments, and
follow-up.
Give the patient a chance to ask any nal
questions.
Ask the patient to repeat the plan back to you.
SOCIAL PHASE
Greet the patient by title and name
Introduce yourself
Smile, make eye contact, shake hands
Refer to patient's last visit (if applicable)
Help patient enter room and get comfortable
Small talk (briefly)
Discuss expectations yours and patient's
What brings you here today?
What can we help you with today?
Im glad you had those tests we talked about
last time. Today we can go over the results
together and discuss the treatment options.
Is there anything else we should leave time to
discuss?"
NEGOTIATE LIMITS IF NECESSARY
Its also important to:
Make eye contact
Show empathy
Nod
Use pauses, phrases (uh huh, go ahead)
Behavioral Observation
Listen to the patient without interrupting
Notice what patient does and how they do it.
Behavior may reveal patient's emotional state
and hidden concerns.
EXPANDING & CLARIFYING THE PATIENTS STORY
OLD CART
Onset
Location
Duration
Character
Aggravating/Alleviating factors
Radiation
Timing
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 Questioning should proceed from general to
OPQRST specific
Onset Start with the most general questions like,
Palliating/Provoking factors How can I help? and move to still open but
Quality focused ones like, Tell me more about your
Radiation experience with the medicine
Site Then pose closed questions like, Did the
Timing new medicine cause any problems?
You should avoid leading questions that
EXPLORE THE PATIENTS PERSPECTIVE include the answer in the question or suggest
Thoughts your desired response
Feelings, fears Using questioning that elicits a
Expectations graded response
Effect of the problem on his life Ask questions that require a graded response
Personal/Family experiences that are similar rather than a single answer
Tried therapeutic approaches How many steps can you climb before you
get short of breath? is better than Do you
NEGOTIATE A PLAN get short of breath climbing stairs?
Feedback and Information Asking a series of questions,
Recommendations one at a time
Treatment plan introduced Any tuberculosis, pleurisy, asthma,
Patient education bronchitis, pneumonia? negative answers
Motivating change (lifestyle) out of sheer confusion
Follow-up plans discussed Be sure to pause and establish eye contact
as you list each problems
PLANNING FOR FOLLOW UP Offering multiple choices for
Let the patient know that the end of the interview answers
is approaching If the patients seem unable to describe their
Allow time for patient to ask questions symptoms without help
Summarize the plan to the patient Clarifying what the patient
Closure to the interview means
If the patients make statements that are
TECHNIQUES OF SKILLED INTERVIEWING ambiguous or have unclear associations
- Active listening and empathy are the golden Encouraging with continuers
links to a therapeutic alliance Use of posture, gestures, or words to
Active listening encourage the patient to say more
Is the process of closely attending to Pausing with a nod of the head or remaining
what the patient is communicating, silent, yet attentive and relaxed cue for the
being aware of the patients emotional patient to continue
state, and using verbal and nonverbal Leaning forward, making eye contact, and
skills to encourage the speaker to using phrases like :Mm-hmm, or Go on, or
continue and expand upon important Im listening all sustain the flow of the
concerns. patients story
Allows you to understand meaning of Using echoing
those concerns at multiple levels of the A simple repetition of the patients last word
patients experience encourages the patient to expand on factual
Guided questioning detail and feelings
Options for expanding and clarifying the This reflective technique help to reveal not
patients story only the location and severity of the pain but
Goal: to facilitate full communication, in also its meaning to the patient
the patients own words, and without
interruption; to absorb the patients story
They may help you to avoid questions
that prestructure or even shut down the Nonverbal communication
flow of the patients idea Communication that does not involve
Types of Guided Questioning speech occurs continuously and
Moving from open-ended to provides important clues to feelings and
focused questions emotions

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 Be aware that some nonverbal language
is universal and some is culturally bound
Bringing nonverbal communication to
the conscious level is the first step to
using this crucial form of patient
interaction
Empathic responses
Vital to patients rapport and healing
Empathy
The capacity of the clinician to
identify with the patient and feel
the patients pain as the
clinicians own
Requires a willingness to suffer
some of the patients pain in the
sharing of suffering that is vital
to healing
To express empathy, you must
first recognize the patients
feelings
Validation
Legitimacy of the patients emotional
experience
Reassurance
The first step to effective reassurance is
simply identifying and acknowledging
the patients feelings (promotes a feeling
of connection)
Partnering
Making patients feel that regardless of
what happens with their illness, you
envision continuing their care
Summarization
It communicates to the patient that you
have been listening carefully
It identifies what you know and what you
dont know
This also allows you, the clinician, to
organize your clinical reasoning and to
convey your thinking to the patient,
making the relationship more
collaborative
Transitions
To put the patient more at ease, tell
them when you are changing directions
during the interview.
Empowering the patient
The clinician-patient relationship is
inherently unequal
DIFFICULT PATIENTS
Silent
Silence has many meanings and
purposes
The period of silence usually feels much
longer to the clinician than it does to the
patient
Be attentive and respectful, convey
encouragement to continue when the
patient is ready
During the period of silence, watch the
patient closely for nonverbal cues, such
as difficulty controlling emotions
At times, silence may be the patients
response to the way you are asking.
Confused
Some patients present a confusing array
of multiple symptoms
They seem to have every symptom that
you ask about, or a positive review
systems
with these patients, focus on the context
of the symptom, emphasizing the
patients perspective, and guide the
interview into a psychosocial
assessment
Patient with altered capacity
Some patients cannot provide their own
histories because of delirium, dementia,
or mental health conditions or unable to
remember certain parts of the history
Determination of the decision- making
capacity of the patient (ability to
understand information related to health,
to make medical choices based on
reason and a consistent set of values,
and to declare preferences about
treatments
Patients with capacity, even if they
communicate only with facial
expressions or gestures, you must
maintain confidentiality and elicit their
input
Patients with impaired capacity, there is
the need of surrogate informant or
decision maker to assist with the history
and decision making; durable power of
attorney for health care or a health care
proxy
Talkative patient
Focus on what seems most important to
the patient
Learn to set limits when needed
Do not show your impatience
Crying patient
Crying signals strong emotions, ranging
from sadness to anger or frustration
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 Usually crying is therapeutic, as is your
quiet acceptance of the patients
distress or pain
Angry or Disruptive patient
Reason for the patient to be angry: they
are ill, they have suffered a loss, they
lack their accustomed control over their
own lives, they feel relatively powerless
in the health care system
Patients displace their anger onto the
clinician as a reflection of their
frustration or pain
Accept angry feelings from patients
Allow them to express their feelings
without getting angry in return
Avoid joining patients in their hostility
towards another provider, clinic, or the
hospital, even if you fell sympathetic
Before approaching overtly disruptive,
belligerent, or out of control patients,
alert the security staff first; as clinician,
maintaining a safe environment is one of
your responsibilities
Stay calm, appear accepting, and avoid
being confrontational
Try to understand what they are saying
The patient with language barrier
Interpreters for optimal health outcomes
and cost-effective care
The patient with low literacy
Assess the patients ability to read
before giving writing instructions
Lack of reading skills may explain why
the patient has not taken medications or
followed recommendations for treatment
Be sensitive to their quandary, and do
not confuse their degree of literacy with
level of intelligence
The patient with hearing impairment
Communication and trust are special
challenges and the risk of
miscommunication is high
Use of Sign Language
Speak at a normal volume and rate and
do not let your voice trail off at the ends
of sentences
Avoid covering your mouth or looking
down at papers while speaking
The blind patient
When meeting with a blind patient,
shake hands to establish contact and
explain who you are and why you are
there
If the room is unfamiliar, orient the
patient to the surroundings and report if
anyone else is present
It still may be helpful to adjust the light
Encourage them to wear glasses
Give full explanations because postures
and gestures are unseen
The patient with limited intelligence
Usually give adequate histories
If you suspect a disability, pay
special attention to the patients
schooling and ability to function
independently
If you are unsure about the patients
level of intelligence, make a smooth
transition to the mental status
examination and assess simple
calculations, vocabulary, memory, and
abstract thinking
For patients with severe mental
retardation, turn to family or caregivers
to
Elicit the history, but always show
interest in the patient first.
The patient with personal problems
Patients may ask you for advice about
personal problems that fall outside the
range of your clinical expertise
Instead of responding, ask about the
different approaches the patient has
considered and related pros and cons,
others who have provided advice, and
what supports are available for different
choices
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 Letting the patient talk through the Repeated injuries/accidents
problem with you is more valuable and Patients partner has history of alcohol or drug
therapeutic than providing the answer abuse
yourself The partner dominates the interview/looks
The seductive patient anxious or solicitous/doesnt leave the room
Clinicians of both genders occasionally
find themselves physically attracted to
their patients. Similarly, patients may
make sexual overtures or exhibit
flirtatious behavior toward clinicians.
The emotional and physical intimacy of
the clinicianpatient relationship may
lend itself to these sexual feelings.
If you become aware of such feelings in
yourself, accept them as a normal
human response, and bring them to
conscious level so they will not affect
your behavior SOCIETAL ASPECTS OF INTERVIEWING
Denying these feelings makes it more
Cultural Humility
likely for you to act inappropriately
Self-awareness
Any sexual contact or romantic
Respectful communication
relationship with patients is unethical;
Collaborative partnerships
keep your relationship with the patient
Sexuality in the Clinician-Patient
within professional bounds, and seek
Relationship
help if you need it.
ETHICS & PROFESSIONALISM
SENSITIVE TOPICS
Nonmaleficence or primum non nocere
First do no harm
Ethics are a set of principles crafted through
reflection and discussion to define right and
wrong

BUILDING BLOCKS

Sexual history
Use specific language private parts
Mental health history
Alcohol (use CAGE questions)
Illicit drugs (use CAGE questions)
Family violence
Death & dying

CAGE
Need to CUT DOWN? TAVISTOCK PRINCIPLES
ANNOYED by criticism? Rights
GUILTY? Balance: patient and community
EYE-OPENER (first drink first thing in the Comprehensiveness: preventive, wellness,
morning) treatment
Cooperation
PHYSICAL ABUSE Improvement
Inconsistent history with unexplained injuries Safety
Delayed treatment for trauma Openness
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Trans by: Team DIYOSA V 2.0
Reference: Trans 2018, 2019, BATES Guide to
th
Physical Examination and History Taking 11 Ed.

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