History Taking

• The most difficult part of the exam is time maintenance. The examination must be completed in 15 minutes.  You must make the optimum use of your time.

Introduction and greeting:

• "Hello Mr. Xyz. Good morning or Good afternoon. I am Dr. xyz. It’s nice to meet you (shake hand).

• Next ask: "What brings you to see me today?" or "What brings you in today?"

• SP will tell you the chief complaint (cc).

• Then ask one open- ended question:  "Could you please describe to me exactly what is going on or more about your problem?"

• After the S. P. gives some extra history ask about any other important facts that haven’t been discussed. 

Location:

• Your initial concern is: "Where is the problem?" or "Can you please show me exactly where it hurts?"

Onset & duration:

• Always ask for the onset and duration of the problem so you can know whether the problem is acute, subacute, or chronic.

• "When did it first start?" or "When did you first notice the problem/pain?"

• If the cc is chest pain: "When did it first start?"

• If the cc is vaginal discharge: "When did you first notice the discharge?"

• Then ask about the onset: "Was the onset all the sudden or progressive?"

• Next, ask follow up questions regarding the cc:

Intensity:
One should always ask about the intensity or severity of the problem, especially if the complaint is pain.

• Ex. "On a scale of 1-10, with 1 being the least painful and 10 being the most painful, which number would describe your pain?" or "How would you grade your pain on a scale of 1-10?" - Ask this way and they will definitely give you a number.

• If the cc is not a pain you can assess its severity by asking questions such as: "How bad is it?" "Does it interfere with your daily activities?" or "Does it interfere with your sleep?"

Quality:

• The quality of the pain may tell you the cause of the pain, i.e. a burning pain as in acid peptic disease and GERD.

• "How do you describe your pain?"

Frequency:

• Always ask about how frequent the problem is?

• Ex." Is it constant?" or "Does it come and go?" If it is intermittent, "How often does it occur? How long does it last? How do you feel between attacks?"

Radiation:

• If the complaint is pain ask questions like, "Does the pain move?" or " Has it changed location?”

Aggravating & Precipitating factors:

Aggravating and precipitating factors might give you a clue as to the cause of the problem.  For example, if food aggregates the epigastric pain a gastric ulcer is most likely the cause.

• Ex1: "What were you doing when it first began? Have you ever found anything that makes your problem/pain worse?"

• Ex2: "Do you have any idea of what might have brought this on?" or "What brings it on?"

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