BUILDING THE HISTORY
The following outline of a patient history is a guideline and should not be considered a rigid structure. You are beginning your relationship with the patient at this point. Take care with this relationship. The information you gain in the history loses meaning if your bond with the patient is less than strong. Choose a comfortable setting and help the patient get settled. Maintain eye contact and use a conversational tone. Begin by introducing yourself and explaining your role. Help the patient understand why you are building the history and how it will be used. Explore positive responses with additional questions: Where, when, what, how, and why. Be sensitive to the patient’s emotions at all times. Avoid confrontation and asking leading questions.
Problem or symptom: Reason for visit
Duration of problem
Patient information: Age, sex, marital status, previous hospital admissions; occupation
Other complaints: Secondary issues, fears, concerns, what made patient seek care
Always consider why this particular problem may be affecting this particular patient at this time. Why did this patient succumb to a risk or an exposure when others similarly exposed did not?
Chronologic ordering: Sequence of events patient has experienced
State of health just before onset of present problem
Complete description of first symptom: Time and date of onset, location, movement
Possible exposure to infection or toxic agents
If symptoms are intermittent, describe typical attack: Onset, duration, symptoms, variations, inciting factors, exacerbating factors, relieving factors
Effect of illness: On lifestyle, on ability to function; limitations imposed by illness
“Stability” of problem: Intensity, variations, improvement, worsening, staying same
Immediate reason for seeking attention, particularly for long-standing problem
Review of appropriate system when there is a conspicuous disturbance of a particular organ or system
Medications: Current and recent, dosage of prescriptions, home remedies, nonprescription medications
Review of chronology of events for each problem: Patient’s confirmations and corrections
GENERAL HEALTH AND STRENGTH
Childhood illnesses: Measles, mumps, whooping cough, chickenpox, smallpox, scarlet fever, acute rheumatic fever, diphtheria, poliomyelitis
Major adult illnesses: Tuberculosis (TB), hepatitis, diabetes, hypertension, myocardial infarction, tropical or parasitic diseases, other infections, any nonsurgical hospital admissions
Immunizations: Poliomyelitis, diphtheria, pertussis, tetanus toxoid, influenza, Haemophilus influenzae B, pneumococcal, cholera, typhus, typhoid, bacille Calmette-Guérin (BCG), hepatitis B virus (HBV), last purified protein derivative (PPD) or other skin tests; unusual reactions to immunizations; tetanus or other antitoxin made with horse serum
Surgery: Dates, hospital, diagnosis, complications
Serious injuries: Resulting disability (document fully for injuries with possible legal implications)
Limitation of ability to function as desired as a result of past events
Medications: Past, current, recent medications; dosage of prescription; home remedies and nonprescription medications, particularly complementary and alternative therapies
Allergies: Especially to medications but also to environmental allergens and foods
Transfusions: Reactions, date, number of units transfused
Emotional status: Mood disorders, psychiatric treatment
Children: Birth, developmental milestones, childhood diseases, immunizations
The genetic basis for a patient’s response to risk or exposure may determine whether the patient becomes ill when others do not.
Relatives with similar illness
Immediate family: Ethnicity, health, cause of and age at death
History of disease: Heart disease, high blood pressure, hypercholesterolemia, cancer, TB, stroke, epilepsy, diabetes, gout, kidney disease, thyroid disease, asthma and other allergic states, forms of arthritis, blood diseases, sexually transmitted diseases, other familial diseases
Spouse and children: Age, health
Hereditary disease: History of grandparents, aunts, uncles, siblings, cousins; consanguinity
PERSONAL AND SOCIAL HISTORY
Personal status: Birthplace, where raised, home environment; parental divorce or separation, socioeconomic class, cultural background, education, position in family, marital status, general life satisfaction, hobbies and interests, sources of stress and strain
Habits: Nutrition and diet; regularity and patterns of eating and sleeping; exercise: quantity and type; quantity of coffee, tea, tobacco, alcohol; illicit and/or recreational drug use: frequency, type, amount; breast or testicular self-examination
Sexual history: Concerns with sexual feelings and performance, frequency of intercourse, ability to achieve orgasm, number and gender of partners
Home conditions: Housing, economic condition, type of health insurance if any, pets and their health
Occupation: Description of usual work and present work if different; list of job changes; work conditions and hours; physical and mental strain; duration of employment; present and past exposure to heat and cold, industrial toxins (especially lead, arsenic, chromium, asbestos, beryllium, poisonous gases, benzene, and polyvinyl chloride or other carcinogens and teratogens); any protective devices required, for example, goggles or masks
Environment: Travel and other exposure to contagious diseases, residence in tropics, water and milk supply, other sources of infection if applicable
Military record: Dates and geographic area of assignments
Complementary and alternative health and medical systems: History and current use
Religious preference: Religious proscriptions concerning medical care
Cost of care: Resources available to patient, financial worries, candid discussion of issues
REVIEW OF SYSTEMS
It is unlikely that all questions in each system will be asked on every occasion. The following questions are among those that should be asked, particularly at the first interview.
General constitutional symptoms: Fever, chills, malaise, fatigability, night sweats, weight (average, preferred, present, change)
Skin, hair, nails: Rash or eruption, itching, pigmentation or texture change, excessive sweating, abnormal nail or hair growth
Head and neck:
General: Frequent or unusual headaches, their location, dizziness, syncope, severe head injuries, periods of loss of consciousness (momentary or prolonged)
Eyes: Visual acuity, blurring, diplopia, photophobia, pain, recent change in appearance or vision, glaucoma, use of eyedrops or other eye medications, history of trauma or familial eye disease
Ears: Hearing loss, pain, discharge, tinnitus, vertigo
Nose: Sense of smell, frequency of colds, obstruction, epistaxis, postnasal discharge, sinus pain
Throat and mouth: Hoarseness or change in voice, frequent sore throats, bleeding or swelling of gums, recent tooth abscesses or extractions, soreness of tongue or buccal mucosa, ulcers, disturbance of taste
Lymph nodes: Enlargement, tenderness, suppuration
Chest and lungs: Pain related to respiration, dyspnea, cyanosis, wheezing, cough, sputum (character and quantity), hemoptysis, night sweats, exposure to TB, date and result of last chest x-ray examination
Breasts: Pain, tenderness, discharge, lumps, galactorrhea, mammograms (screening or diagnostic), frequency of self-examination
Heart and blood vessels: Chest pain or distress, precipitating causes, timing and duration, character, relieving factors, palpitations, dyspnea, orthopnea (number of pillows needed), edema, claudication, hypertension, previous myocardial infarction, estimate of exercise tolerance, past electrocardiogram (ECG) or other cardiac tests
Peripheral vasculature: Claudication (frequency, severity), tendency to bruise or bleed, thromboses, thrombophlebitis
Hematologic: Any known abnormality of blood cells, transfusions
Gastrointestinal: Appetite, digestion, intolerance of any class of foods, dysphagia, heartburn, nausea, vomiting, hematemesis; regularity of bowels, constipation, diarrhea, change in stool color or contents (clay colored, tarry, fresh blood, mucus, undigested food), flatulence, hemorrhoids; hepatitis, jaundice, dark urine; history of ulcer, gallstones, polyps, tumor; previous x-ray examinations (where, when, findings)
Diet: Appetite, likes and dislikes, restrictions (e.g., because of religion, allergy, or other disease), vitamins and other supplements, use of caffeine-containing beverages (e.g., coffee, tea, cola), an hour-by-hour detailing of food and liquid intake—sometimes a written diary covering several days of intake may be necessary
Endocrine: Thyroid enlargement or tenderness, heat or cold intolerance, unexplained weight change, diabetes, polydipsia, polyuria, changes in facial or body hair, increased hat and glove size, skin striae
Menses: Onset, regularity, duration and amount of flow, dysmenorrhea, date of last menstrual period (LMP), intermenstrual discharge or bleeding, itching, date of last Pap smear, age at menopause, libido, frequency of intercourse, sexual difficulties, infertility
Pregnancies: Number, living children, multiple births, miscarriages, abortions, duration of pregnancies, type of delivery for each, any complications during any pregnancy or postpartum period or with neonate, use of oral or other contraceptives, difficulty in getting pregnant
Males: Puberty onset, difficulty with erections, emissions, testicular pain, libido, infertility
Genitourinary: Dysuria, flank or suprapubic pain, urgency, frequency, nocturia, hematuria, polyuria, hesitancy, dribbling, loss in force of stream, passage of stone, edema of face, stress incontinence, hernias, sexually transmitted disease (inquire type and symptoms and results of serologic test for syphilis [STS], if known)
Musculoskeletal: Joint stiffness, pain, restriction of motion, swelling, redness, heat, bony deformity
Neurologic: Syncope, seizures, weakness or paralysis, abnormalities of sensation or coordination, tremors, loss of memory
Psychiatric: Depression, mood changes, difficulty concentrating, nervousness, tension, suicidal thoughts, irritability, sleep disturbances
In conclusion, ask:
Is there anything else that you think would be important for me to know?
If there are several problems: Which concerns you the most?
If the history is vague, complicated, or contradictory: What do you think is the matter with you, or, what worries you the most?
BUILDING THE HISTORY
These are only guidelines; you are free to modify and add as the needs of your patients and your judgment dictate.
A parent or other responsible adult will generally be the major resource. When age permits, however, the child should be involved as much as possible. Remember that every chief complaint has the potential of an underlying concern. What really led to the visit to you? Was it just the sore throat?
Note relationship to patient of person who is the resource for history, and record your impression of the competence of that person as a historian.
Be sure to give a clear chronologic sequence to the story.
In general, the age of the patient and the nature of the problem will guide your approach. Clearly, in a continuing relationship much of what is to be known will already have been recorded. Certainly, different aspects of the history require varying emphasis depending on the nature of the immediate problem. There are specifics that will command attention.
Infectious disease; give approximate gestational month
Bleeding; approximate time
Eclampsia, threat of eclampsia
Special or unusual diet or dietary practices
Medications (hormones, vitamins)
Quality of fetal movements, time of onset
Birth and perinatal experience:
Duration of pregnancy
Labor: Spontaneous/induced, duration, anesthesia, complications
Delivery: Presentation; forceps/spontaneous; complications
Condition at birth: Time of onset of cry; Apgar scores, if available
Birth weight and, if available, length and head circumference
Hospital experience: Length of stay, feeding experience, oxygen needs, vigor, color (jaundice, cyanosis), cry. Did baby go home with mother?
First month of life: Color (jaundice), feeding, vigor, any suggestion of illness or untoward event
Bottle or breast: Any changes and why; type of formula, amounts offered/taken, feeding frequency; weight gain
Present diet and appetite: Introduction of solids, current routine and frequency, age weaned from bottle or breast, daily intake of milk, food preferences, ability to feed self; elaborate on any feeding problems
Guidelines suggested in Chapter 21, Age-Specific Examination: Infants, Children, and Adolescents, are complementary to the milestones listed below. Those included here are commonly used, often remembered, and often recorded in “baby books.” Photographs also may occasionally be of some help. note: It is important to define the growth and developmental status of each child regardless of the particular complaint. That status will inform your understanding of the child, and of the particular problem, and will facilitate the institution of a management plan.
Held head erect while held in sitting position
Sat alone, unsupported
Talked in sentences
School: Grade, performance, learning and social problems
Dentition: Ages for first teeth, loss of deciduous teeth, first permanent teeth
Growth: Height and weight at different ages, changes in rate of growth or weight gain or loss
Sexual: Present status (e.g., in female, time of breast development, nipples, pubic hair, description of menses; in males, development of pubic hair, voice change, acne, emissions). Follow Tanner guides
Maternal gestational history: All pregnancies with status of each, including date, age, cause of death of all deceased siblings, and dates and duration of pregnancy in the case of miscarriages; mother’s health during pregnancy
Age of parents at birth of patient
Are parents related to each other in any way?
PERSONAL AND SOCIAL HISTORY
Principal caretaker(s) of patient
Food preparation, routine, family preferences (e.g., vegetarianism), who does preparing
Adequacy of clothing
Dependency on relief or social agencies
Number of persons and rooms in house or apartment
Sleeping routines and sleep arrangements for child
REVIEW OF SYSTEMS (SOME SUGGESTED ADDITIONAL QUESTIONS OR PARTICULAR CONCERNS)
Ears: Otitis media (frequency, laterality)
Nose: Snoring, mouth breathing
Teeth: Dental care
Genitourinary: Nature of urinary stream, forceful or a dribble
Skin, hair, nails: Eczema or seborrhoea