Clinical history taking is the art of extracting the smallest of information from the patient and reaching a possible diagnosis. For Medical (especially MBBS) students and Interns, Medical History is an important task to learn, understand and interpret in order to become a professional Doctor.
Without a proper clinical history taking format, you are definitely not going to pass the practical exams indeed. Here we present the basic layout of taking medical history template which can be used to avoid missing important points. If we still missed steps, don’t forget to point it out.
NOTE: Always remember standing on RIGHT SIDE of patient while taking the history.
Particulars of Patient
Following are general particulars you need to note in Clinical history taking format:
7. D.O.A (Date Of Admission)
8. D.O.E (Date Of Examination)
Medical History Template includes the following points:
1. C/C (Chief Complaints)
2. HOPI (History Of Present Illness)
3. Past history
4. Personal history
5. Family history
6. Rx history (Treatment history)
7. Psychological history
8. Menstrual/Obs. history in females
1. Chief Complaints
Major complaints with a duration should be written in the patient’s native language in the order in which they emerge.
2. History of Present Illness
- Progression of the main complaints in terms of onset (acute/subacute/insidious), course (progressive/static/with exacerbations and remissions), and duration. It is necessary to inquire about the patient’s progress while in the hospital.
- Positive points, as well as significant negative aspects (e.g., paralysis in neurological disorders or breathlessness in cardiovascular diseases).
- As far as possible, use the patient’s own words and avoid scientific or medical terminology (joint pain is a preferable term to arthritis).
- Do not ask leading questions (questions that indicate their own answers), yet straight appropriate inquiries are often a crucial component of careful history-taking.
- Keep track of any relevant related symptoms.
- Generalities — Appetite (LOA), weight loss (LOW), exhaustion, sleep, bladder, and bowel problems.
- Personal history may also include bladder and bowel habits.
3. Past History
The past history in clinical history format should include:
- TB (Tuberculosis) (including contact with any affected individual)
- Rheumatic fever
- Sexually Transmitted Diseases (STDs) (including any exposure to affected individuals)
- Systemic HTN (hypertension)
- Any past trauma or injury
- Previous blood transfusion with reason
- Any childhood illness
- Any history of hospitalization
- Any major medical/psychological illness
- Traveling history
- Hypertension and DM can be taken in personal history as well.
- Avoid using “No significant personal history”. Instead, you should state- “Patient has no past history of TB, Jaundice, etc.”
- In pediatric patients, history of birth (birth asphyxia), immunization, any history of injury, umbilical sepsis, or meningitis should be promptly taken from parents/guardians.
4. Personal History
In this section of the medical history template, just the patient, spouse, and children are included. The following aspects (for example, personal information and lifestyle) should be carefully noted:
- Marital status, as well as the number of children.
- Employment (nature of occupation and environment of the job) education and whether unemployed or not.
Income (indirectly inquired) and social (socio-economic) status.
- Addiction (tea. coffee, smoking, alcoholism, or drug misuse e.g., chewing tobacco, cannabis, heroin; try to determine the amount of intake of cigarettes or alcohol).
- Dietary routine (for diagnosis of avitaminosis, malnutrition, obesity).
- Contraception history.
- Whether they exercise on a regular basis or not?
- High-risk behavior (e.g., IV drug misuse, repeated unprotected sexual encounters, homosexuality, and so on) is crucial in hepatitis B or C infection, AIDS, and SBE.
- Domestic and marital relationships, as well as hobbies and pets.
- Tobacco abuse: the kind (cigarette/biri), quantity, and length of exposure.
5. Family History
- This comprises the parents, siblings, uncles (maternal or paternal), nephews, and so on.
- History of TB (affected by contact), diabetes, systemic hypertension, ischemic heart disease (IHD), bronchial asthma, eczema, hemophilia, thalassemia, and schizophrenia should be investigated in the family.
- A history of comparable types of sickness (like the patient’s) in the family should be requested. The cause of death of close relatives (parents) should be stated.
- Any history of consanguineous marriages within the family should be documented (consanguineous matings might result in autosomal recessive illnesses such as homocystinuria).
- In hereditary and communicable illnesses, family history is crucial (e.g., mumps, measles, chickenpox).
- Environmental considerations, such as the consequences of passive smoking in a woman with a heavy-smoker spouse, should always be considered.
- Finally, a ‘pedigree chart’ (symbols utilized in the building of a family) may be created.
6. Treatment History
- Treatment for the current disease that the patient has obtained so far.
- Any history of medication allergies or adverse effects.
- Any substantial surgical intervention or history of incidents in the past.
- Prolonged usage of oral contraceptives (may cause CVA), penicillamine (used in Wilson’s disease; may cause nephrotic syndrome), or vitamin C (may cause oxalate stone), among other things.
- Blood transfusion—frequency, quantity, and type (e.g., whole blood, packed cell).
- NSAID consumption (may produce acute gastric erosion, NSAID-induced asthma, etc.).
- If frequently using oral contraceptives, vitamins, laxatives, sedatives, or herbal medicines.
7. Psychological History
Examine the patient’s mood, that is, if anxiety, sadness, irritability, euphoria, preoccupation, neurosis, or depersonalization are present or not. Psychosomatic disorders include peptic ulcer, bronchial asthma, and irritable bowel syndrome.
8. Menstrual and Obstetric History
These should include:
- Duration of menses
- Quantity of blood loss (typically assessed by the number of pads or passage of clots)
- Any amenorrhea, dysmenorrhea, or menstrual irregularities
- LMP (Last Menstrual Period)
- Menopause or any post-menopausal bleeding
- Number of pregnancies
- Pregnancy outcome; history of abortions or brought to term; live birth (male/female)
- Challenges during pregnancy (e.g.. hypertension, gestational diabetes mellitus)
- Manner of delivery (vaginal, forceps. Caesarean)
- Most recent childbirth
- While filling the medical history template, complete attention is provided to the patient, and communication difficulties (foreign visitors, trouble hearing/vision, dysphasic/aphasic patient, emotionally disturbed i.e., angry or abusive patient) may be addressed by information gathered from a relative.
- Recognize nonverbal cues in the patient (e.g., shortness of breath, flushing, restlessness, or shifting eye contact are all symptoms of stress).
- When taking a history, one must use extreme caution when dealing with very sensitive issues such as drug addiction, eating disorders, marital discord, sexual abuse, or offensive behavior.
- Remember that in the case of females, menstruation or pregnancy may have a triggering effect on migraine or heart failure.
During the history-taking process, be compassionate and patient, and always attempt to be on the patient’s level in every way. Only through practice can history-taking abilities be acquired and maintained adequately.
A general physical examination (GPE) and a systemic examination are performed during the clinical history taking:
- Level of consciousness– whether the patient is alert, cooperative, and oriented to time and space
- Apparent age– The patient may look younger in Down’s syndrome, Thallasaemia, Pituitary dwarf or the patient may look older than his/her age in Progeria (An extremely rare genetic disorder in which aging occurs at a very early age) or Precocious puberty (development at an earlier age than usual)
- Decubitus (Position of the patient)
- Built– Average/Dwarf/Tall stature
- Nutrition– Average/Underweight/Obese (try to get BMI)
- Facial appearance
- Neck vein (J.V.P, J.V engorgement, J.V pulse)
- Neck artery (Carotid arteries)
- L.N (Lymph nodes all over the body)
- Thyroid gland
- Koilonychia (Spoon nails) – Hypochromic anemia in Iron deficiency anemia
- Pulse– Rate, Rhythm, Volume, Condition of the arterial wall, Comparison b/w 2 radial pulses, Radiofemoral delay, any special character, Other peripheral pulses
- Respiration– Rate, Rhythm, Depth, Breathing pattern)
- Temperature– Oral temperature for Fever
- B.P (Blood pressure in mm Hg)
- Skin, Hair, Nails
- Height and Weight
- Any obvious deformity of the skull, spine, or limbs, swelling of the abdomen
- General– any acute distress present or not
- Handedness (Right/Left) with the level of intelligence (Average/Low/High)
- CVS (Cardiovascular system)
- Respiratory system
- GIT (Gastrointestinal tract) system
- Nervous system
- Genitourinary system
- Lymphoreticular system
- Locomotor system (Optional)
Summary of Case
It should be in a few lines, explaining the general information of the patient and then key points. Always reach 5 points during medical history taking:
- C/C (Chief Complaints) of patient
- Organ system affected
- The onset of symptoms (Acute/Chronic)
- Etiology (Infectious, inflammatory, traumatic, genetic, etc.)
- Possible diagnosis
So, it could be like this- Patient named xxx aged xx years presented on xx/xx/xx dates with such and such complaints. the xx systems appeared to be affected and on examination, xx disease/symptom was revealed which was acute/chronic in onset and having xx possible etiology. The provisional diagnosis appears to be xx.
The most possible diagnosis you can make out of the case.
Make a list of possible diagnoses and rule them out individually to reach the exact diagnosis.
Certain investigations like X-ray, USG, ct, etc can be asked for more detailed information.
Following are some useful articles that you can use to further enhance your clinical history taking format:
- Respiratory System Examination
- Auscultation of Lungs: Guide for Wards
- Normal Breath Sounds on Auscultation
- Cough History Taking
- Fever History Taking