History taking is an art that should be conquered by every medical student for proper diagnosis and care of the patient.
A. Patient data
- Name
- Age
- Sex
- Address
- Occupation
- Religion
B. History taking
- Chief complaints
- History of present illness
- Past history
- Personal history
- Family history
- History of treatment
- History of allergy
- History of immunization
- History of bleeding disorders
- OBG History (Female)
C. Chief complaints
Pain
SOCRATES (pneumonics of pain in history taking)
- Site
- Onset (Mode)
- Progression
- Character
- Radiation/ Referred pain
- Associated symptoms
- Time/ Duration
- Exacerbating factors/ Relieving factors
- Severity
- Night cry: Tuberculosis of the spine
- Rest pain: Avascular necrosis
- Pain in other joints
Onset: Sudden/ Insidious
Difference between inflammatory, mechanical, and neoplastic pain
| Pain | Aggravating factor | Relieving factor |
| Mechanical | Activity | Rest |
| Inflammatory | Rest | Activity |
| Infective/ Neoplastic | Activity | None |
Progression
- Constant nagging pain day/ night = neoplasm
- Increase and decrease= Trauma
- Sudden increase and decrease = Acute inflammation
- Remission and exacerbation = Chronic arthritis
- The sudden increase in pain in swelling=? malignancy
Character
- Sharp- muscle strain/ tear, fracture
- Dull- Osteoarthritis , Rheumatoid arthritis
- Aching- Chronic arthritis, AVN
- Throbbing- Abscess, Acute osteomyelitis
- Burning- Neuralgia
Radiation
- Sciatica: can run from the hip down the back of the thigh into the foot
- Radiates to the groin can imply inguinal hernia or groin strain
Site/ Severity
- Mild/ Moderate/ Severe
- How does the pain affect your daily life?
- How far can they walk? (Walking distance gradually decreases)
- Difficulty in walking up and downstairs?
- Are they still able to do their daily activities/ favorite hobbies?
- Have their partners noticed their pain limiting them?
- Are they taking regular analgesia?
Swelling
- Site
- Onset
- Duration
- Associated with pain/ pain;ess
- Progression over time
- Multiple swelling
Limp
- Usually noted by attender
- Onset
- Duration
- Associated with pain
- Progression
- Ambulatory status
| Painful limp | Painless limp |
|---|---|
| Traumatic | Poliomyelitis |
| Inflammatory | Developmental dysplasia of Hip |
| Osteoarthritis of Hip | Coxa vara |
| Perthe’s disease | Ankylosed |
Deformity
If trauma= malunion, VIC, unreduced dislocation
Acute pain = Muscle spasm
Gradual progression chronic infections= Triple deformity
Other Significant History
- History of contact with TB patient (active)
- History of trauma
- Constitutional symptoms: Loss of appetite, Significant weight loss
- History of steroid uptake
- Sleep disturbances
Functional History
- Squatting, Sitting crossed leg
- Daily activities
Past History
- Trauma
- Tuberculosis
- Surgery around hip
- Skin/ hematological disorder
- Neurological disorder
- Connective tissue disorders
- Steroid intake
- Any other significant medical and surgical illness
Personal History
With pneumonics ABCDEF
A= Allergy, Alcoholism. Addiction
B= Birth trauma, Bleeding disorder
C= Contact to TB
D= Drug intake
E= Environmental -> Lives in pakka house with an annual income of …
F= Family History suggestive of family disease, infection: TB
Family History
- TB in close relatives
- Dysplasia
- Metabolic storage disease
- Inflammatory arthritis
