establish rapport well come patients

introduce self I am first year medical students I am asked by my senior doctor to take a history from
you it may take 15 minutes is that is OK
may I know your name please then continue
opening statement : how can I help you /what brought you today
personal details:
• Name, • age, • address, • sex, • ethnicity, • occupation, • religion, • marital status.
• Special habits of medical importance.
• Record date of examination
• Chief Complaint (CC)
• Short/specific in one clear sentence communicating present/major problem/issue.
• Timing –
• Recurrent –
• pain/cough
• Note: CC should be put in patient language
History of Present Illness tips
Elaborate on the chief complaint in detail
For each symptom determine :
The Onset:
The date began ,
How it began(suddenly or gradual over how long)
If the symptoms since long time why he seeks help now?
Periodicity and frequency:
Constant or intermittent?
How long does is last each time ?
What is the exact manner in which it comes and go?
Change over time :
Improving or deteriorating?
Exacerbating factors: what make it worse?
Relieving factors: what make it better
Associated symptoms:
 Sequential presentation
 How the problem start

 Past Medical History

 Past medical problems (chronic diseases)
 IHD/Heart Attack/DM/Asthma/HT/RHD,
 TB/Jaundice/Fits :E.g. if diabetic- mention time
 of diagnosis/current medication/clinic check up
 Past Surgical History
 These are any previous operations that the patient may have had Make sure to put how old
the patient was when they occurred

Drug History name in brackets with dosage, timing and how long./OCP/VIT
 Allergies : latex, food and seasonal allergies, medication allergies
Family history
• Ask if the patient’s parents, grandparents, siblings or other family members had any major medical
conditions
• Heart disease, heart attacks, hypertension, hyperlipidaemia, diabetes, sickle cell disease
Any familial disease/running in families e.g. breast cancer, IHD, DM,HTN schizophrenia,
Developmental delay, asthma etc.
 • Positive and negative consanguinity for pediatric history
Social history
socioeconomic
Smoking history - amount, duration and type. A strong risk factor for IHD
Drinking history - amount, duration and type. Cause cardiomyopathy, vasodilatation
Occupation, social and education background, family social support and financial situation
System Review (SR)
• The review of systems is just that, a series of questions grouped by organ system including: •
General
 • Skin/Breast
 • Eyes/Ears/Nose/Mouth/Throat • Cardiovascular
 • Respiratory
 • Gastrointestinal
 • Genitourinary
 • Musculoskeletal
 • Neurologic/Psychiatric • Allergic/Immunologic/Lymphatic/Endocrine
questions to ask about characteristic of PAIN

SOCRATES is a mnemonic acronym

Site – Where is the pain? Or the maximal site of the pain. Ask the patient to point to the sit with his
finger

Onset – When did the pain start, and was it sudden or gradual? Include also whether if it is progressive
or regressive.

Character – What is the pain like? An ache? Stabbing? Dull? Burning?

Radiation – Does the pain radiate anywhere?

Associations – Any other signs or symptoms associated with the pain? Nausea shortness of breath

Time course – Does the pain follow any pattern?

Exacerbating/Relieving factors – Does anything change the pain?

• Severity – How bad is the pain ( 0-10)