How to take History of a Patient in an impressive way

A good history taken is a one step closer to accurate diagnosis of a case. But, a weak history
takes you three steps away. And you know the importance of proper diagnosis.

It is one of the important skill which can make you distinct to other physiotherapists.

so let us try to understand why it is so important? By the time you finishes reading it I hope you
will come out little better than what you were before.

History taking is process of collecting information from patient and trying to look for the clue
which may have contributed to the present problem. It involves reviewing the medical report
and direct conversation with patient.

Conversation with patient is important. But, one need to be a better listener to extract
information from them. You just put a simple question and leave them to patient to speak on it.

But, some patient is shy or a less talkative kind and may not be possible to get relevant
information from them spontaneously. For them you have to put the question strategically and
try to extract the information.

In my practice, I first scan all the previous medical report and then start my conversation. My
first question to them depends on how they came to me. We will discuss more on this topic, but
let me explain you what I mean, by one of this example.

Suppose a patient is an self-referrer, who came to me after going to numerous doctors and
hospitals. He/ she is already exhausted by the medical system and if I start my question with
what is your problem, it may (or may not but most probably) irritate her.

In such scenario, my first question would be "does all these treatments worked?". This simple
question is bound to extract all her frustration on whatever she had gone through without
being getting the benefit of a single penny. You just need to hear it patiently.

So, what I get by this?.....

Simple, with a single question it gave me crucial information of what treatment is working and
what is not. I will simply exclude the thing which is not working. Just practice and see what you
get.

In this article, we will discuss how to take the history of a patient, what is the proper approach.

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Why history is important?

History of patient helps in better understanding of the present illness. It gives an overall idea of
in which direction we have to take the examination, test and diagnosis.

For example, a patient complains of back pain which refers to lower limb. According to the
history of occupation, his job is to sit in front of computers of hours. The complain of pain may
suggest disc prolapsed but his job history gives an idea that it may be a chronic case of back
pain. So we can direct our examination in both the direction to rule out one of the cause.

Some of the diagnosis can be made out by the history itself. If a patient comes with pain in the
one side of hip joint and is past medical history shows that he was being given IV
corticosteroids. This makes the picture more clear that the pain is due to avascular necrosis of
hip joint.

How to take history.

Information about patients past illness and present illness can be taken by reviewing the past
medical records and taking interview of the patient.

We will discuss later, on how to take effective interview of the patient. Because if you take
interview of patient like and examiner, it will sound too mechanical. It is during the interview
that one has to develop the good rapport with the patient.
The process of history taking.
Process I am going to describe is the most standard process used. You may skip one or two
depeding on the chief complain of the patient.

For example, if a post-operative patient comes to you, there is no use taking family history. But,
if a low back pain comes with complain of pain on small joints of finger, then the family history
is very crucial here.

with the experience, history taking will become a spontaneous process. You will take all
history as if you a are simply talking to you patient.

So, here is the process of history taking:

General demographics:
1. Name

2. Age

3. Sex

4. Address (region)

Occupation.
1. Current job

2. Nature of current job

3. Past job and its nature

4. Period of current job

History of current illness.

1. What illness or disability made them to approach you.

2. Who referred to you.

3. Duration of present bout of illness.

4. History of any bouts of present illness.

5. Mechanism of injury

6. How the pain started

7. Onset and pattern of pain.

8. Pain reliving factors

Treatment history.
1. Medication for current illness.

2. History of past physiotherapy treatment.

3. Medication for other conditions.

History of test and diagnosis.

1. Review old X-Ray report.

2. Scan through old CT-scan/ MRI reports.

3. Review all available records.

History of past illness.

1. History of past illness.

2. History of past surgeries and implants.

3. Diabetes, blood pressure.

Family history.
1. History of any one in family suffering from present illness.

Social habits.
1. Addiction to smoking, drinking .

2. Drug abuse.

3. Interest in self care, physical fitness.

Conclusion.

For me, history taking is an art. If you master the art you can collect all the information on the
points mentioned above in a free flow manner. You are talking to your patient and collecting
information without giving patient hint of being interviewed as an examiner. With practice and
experience any one can master the art of history taking.