The Arts of History Taking 1

Chief Complaints

- Chief complaints is what brings patient to the hospitals

- It is described in patient’s own words

- Some patient might have more than one complaint; therefore it is crucial to identify what is the most significant presentation.

- If the complaints are related to each others, then put it in chronological orders.

- It should be short and concise

- Give rough idea on what patient’s suffered from.

- If patient have pre existing disease, it should not be mentioned in chief complaint.

- Examples

a) Patient is a known case of diabetes mellitus with previous admission to hospitals due to diabetic complication. Currently patient presented to you because of right foot ulcer since 3 days ago. Therefore, you need to emphasize why he came to hospitals only after 3 days.

Eg; Worsened right foot ulcer for 3/7 duration.

b) Patient has peptic ulcer disease but now complaint of severe abdominal pain at epigastrium since morning. This pain is not like previous pain that he experienced. And patient also complaint of lethargy and cold hand. Therefore, you can put the chief complaint as follow

Eg; sudden onset severe abdominal pain since morning associated with lethargy and cold extremities.

c) Patient complaint of typical myocardial infarction and associated symptoms. In chief complaint, you don’t have to describe about the chest pain. Just put it simply as

Eg; Left sided chest pain associated with nausea, vomiting and palpitation 30 minutes prior to presentation

History of presenting illness (HOPI)

In this section, you are tried to evaluate the patient’s condition, diagnosis and differentials. It should be described in patient’s words but not everything must be presented. You should think what is related to the complaint. In presenting HOPI, you can use the 4 steps approach.

a) Elaborate on patient’s presentation of chief complaints. You may use mnemonic LORD SANFARO

o L- Location

o O- Onset

o R- Radiation

o D- Duration

o S- Severity

o A- Aggravating factor

o N- Nature

o F-Frequency

o A- Associated factors

o R- Relieving factors

o O- Offset

b) Complication of the chief complaint

o For examples, patient with perforated peptic ulcer may have symptoms of peritonitis. Patient with upper GIT bleed may have symptoms of anemia or develop ischemic heart disease. Therefore, you should catch this complication

c) Questions to exclude other differentials

o In order to ask relevant question to exclude diagnosis, you need to have a good knowledge. Patient presented with chest pain could be due to heart, lung, musculoskeletal system, thorax, vessel or radiating pain from stomach and biliary tract.

d) What have been done to the patient

o Give an outline of what investigation or treatment that patient has undergone.