How to take a Medical History

The first step towards treating any patient is making a correct diagnosis. The diagnostic sequence can be divided into five levels:
1. History taking
2. Clinical examination
3. Radiological analysis
4. Laboratory investigations
5. Interpretation and final diagnosis

What is the aim of History Taking? 

The aim of history taking is to obtain a correct account of the patient’s problems, taking into consideration his/her symptoms, general condition, lifestyle, and socioeconomic background.

Steps in History Taking: 

There are following steps while taking History of a patient.

  • General Information
  • Chief Complaint/s
  • Past/Present Medical History
  • Personal and Family History

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1:  General Information:

The first step in history taking is to obtain general information about the patient regarding the name, age, sex, marital status, address, race and occupation.

2: Chief Complaint/s: 

The chief complaint ascertains the principal reason as to why the patient is seeking medical attention. The following details are recorded:

1. All the symptoms, chronologically, in the patient’s own words.
2. The onset, duration and progress of each of these symptoms.
3. Any treatment taken earlier for the condition, and the patient’s response to the same.
4. A previous history of similar symptoms and treatment
taken for the same, along with the outcome.
5. If the patient gives a history of trauma, additional history regarding unconsciousness, vomiting, bleeding from mouth, ear, nose or throat, retro/ anterograde amnesia is obtained.

3. Past/Present Medical History:

A detailed picture of the general medical status of the
patient is obtained, which may or may not bear
relevance to the chief complaint, the management of
the patient and outcome of the treatment. The medical
history questionnaire should include a detailed history
of the following:
1. Cardiovascular disorders like myocardial infarction, ischemic heart disease, rheumatic heart disease, angina, valvular septal defect, hypertension and congestive cardiac failure. All the medications taken by the patient are listed including details
about anticoagulants, antihypertensive drug therapy.
2. Diseases of the respiratory system such as chronic obstructive pulmonary disease, bronchial asthma, pneumonia, pleuritis, bronchitis, upper respiratory tract infections. These patients may
be on bronchodilators, antihistaminics or steroid therapy. Any disease of the respiratory system significantly affects the anaesthetic management of the patient. A history of sleep apnea may be obtained from the relatives. This condition is commonly seen in patients with severe mandibular retrusion secondary to bilateral temporomandibular joint ankylosis.
3. Neurologic conditions like, epilepsy, hemi/ paraplegia and past history of head injury and medications taken for the same. If the patient is an epileptic, then the last episode of seizure and the frequency of seizure episodes are recorded.
4. Diseases of the endocrine system including thyroid disorders, diabetes, adrenal pheochromocytoma, and multiple endocrine neoplasia and medications taken for the same. If the patient is a
diabetic, care must be taken to mention his/her latest blood sugar values and the route of administration of the antidiabetic therapy, i.e., oral drugs or insulin injections.
5. Haematological disorders like anaemias, leukaemia, haemophilia, platelet count abnormalities, etc. and the last available blood reports pertaining to the condition.
6. Infectious diseases like tuberculosis, syphilis, viral hepatitis, herpes, and other sexually transmitted diseases.
7. Reproductive system pregnancy, lactation, last
menstrual cycle, number of children, abortions
and use of oral contraceptives. Many common
antibiotics are known to have interactions with
oral contraceptives rendering them ineffective.
The patient must then be advised to practice
alternate methods of birth control for the period.
8. Gastric disorders like peptic ulcer, acidity
problems, vomiting, and diarrhoea.
9. Renal pathologies like glomerulonephritis,
nephrotic syndrome, renal failure, and patients
on dialysis.
10. Disorders of the liver like cirrhosis, alcoholic liver
disease, hepatitis.
11. Autoimmune disorders like systemic lupus
erythematosus, scleroderma, requiring long-term
corticosteroid therapy.
12. Psychiatric ailments and treatment taken for the
same.
13. Digestive system loss of appetite, loss of weight,
polydipsia, polyuria.
14. Allergy to any drug.
15. Childhood illness/birth trauma.
16. Details of previous hospitalization, blood transfusions and surgeries.
17. Past/present history of radiation therapy.
18. Current/past medications taken, e.g. NSAIDs for chronic inflammatory lesions, aspirin, anticoagulant
therapy, antikoch’s therapy, steroid therapy for autoimmune disorders.
Any of the above conditions can alter the patient’s response to surgery and influence both the anaesthetic and surgical management of the patient as well as postoperative recovery and wound healing.

4. Personal and Family History
This part of the history deals with both the personal
habits as well as social history of the patient. It gives
an overview of the patient’s lifestyle. This gives a better
perspective of the patient apart from contributing to
the diagnosis of the disease as well as outcome of the
treatment.
1. Habits like chewing tobacco, quicklime, areca nut, pan masala, gutkha, chronic alcoholism, chronic smoking, drug abuse and frequent exposure to commercial sex workers.
2. A detailed history of the immediate family of the patient, with their age, general health status, medical ailments, cause and age at the time of death of any deceased member is recorded. A family
history of epilepsy, cardiac disorders, diabetes, bleeding disorders, and tuberculosis is of particular importance.



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