Class notes
History taking notes for medical students
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Hi. These are some notes I made from class pertaining on how to take history from patients presenting with common conditions like cough, epigastric pain etc.
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HISTORY TAKING- Introduction + consent + confirm patient details (name, age, gender,
nationality, address, occupation)
- What brought you to the PHC today? How long has it been happening?
ANEMIA
- Fatigue, lethargy
- Headache
- Palpitations
- Pale skin or conjunctiva
- Dyspnoea
- Hair loss
- Less common symptoms :
- Restless leg syndrome
- Pica (a craving non-food substances, such as ice or dirt – commonly seen in
children and pregnant women)
- Tinnitus
- Pruritus
- Mouth ulcers
- Vertigo/dizziness
- Underlying diseases associated with iron deficiency anaemia-
- Dysphagia: oesophageal malignancy, plummer vilson
- Dyspepsia / indigestion: gastric cancer, peptic ulcer disease
- Abdominal pain: coeliac disease, malignancy, inflammatory bowel disease
- Change in bowel habit: bowel cancer, coeliac disease, inflammatory bowel
disease
- Rectal bleeding: anal fissure, rectal cancer, haemorrhoids, inflammatory
bowel disease
- Change in urine color - haemolytic anemia
- Weight loss: inflammatory bowel disease, bowel cancer
- Past medical history
- Past surgical history
- Past drug and allergy history - OTCs, vitamins, nsaids, ocp (females)
- Past family history - anemia, jaundice, cholelithiasis, splenectomy, bleeding
disorders, and abnormal hemoglobins
- Diet history - pica, chewing ice
- Social history - smoking + exercise + pets + travel + household exposures to
potentially noxious agents
- Menstrual history - are they regular? Cycle length? Menorrhagia?
Pregnancies, abortions? OCP use
- ICE - IDEAS, CONCERNS, EXPECTATIONS
, DIARRHEA
- Duration - acute (<14 days), chronic (>14 days) or intermittent?
- Onset - when did it start?
- Frequency
- Is there tenesmus, urgency or incontinence?
- Consistency, volume:
- watery, unformed or semisolid?
- large-volume and not excessively frequent (small-bowel disease)?
- small-volume and excessively frequent (large-bowel disease)?
- associated with blood, mucus or pus?
- Shape of stool and smell
- Color
- Blood / mucus in stool
- Timing - day or night = Is sleep disturbed by diarrhoea, suggesting organic
disease?
- Any other gastrointestinal symptom, e.g. abdominal pain and vomiting?
- Any exacerbating/ relieving factors?
- Any one else in family has symptoms?
- Past medical history - IBD, gastrointestinal
- Past surgical history - GI surgery, bowel obstruction
- Family history of gastrointestinal disorder, e.g. gluten enteropathy, Crohn’s?
- Drug and allergy history - laxatives? Antibiotics? Antidepressants
- Diet history - anything from outside?
- Travel history - any endemic areas? contact with contaminated water?
- Social history - smoking, alcohol, exercise, accomodation (close living
spaces)
- Females - menstrual history
- ICE
PEPTIC ULCER
- Burning epigastric pain -
- After meals - gastric
- Relieved by meals - duodenal
- Awaken at night? - duodenal
- Gradual pain
- Radiating to back
- Pain typically follows a daily pattern specific to the patient. + remission for
weeks/ months
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