Inquiry and History Taking
1. Inquiry (Wen Zhen)
Definition: The process of obtaining medical history from the patient and related individuals. It is the primary method of history taking (History taking).
2. Importance of Inquiry
1. Systematic questioning of the patient or related individuals is an important means of collecting clinical data. It is a fundamental skill that clinical practitioners must master.
2. It allows for understanding the occurrence and development of diseases, treatment processes, past health conditions, and previous illnesses.
3. The information obtained provides important clues for diagnosis, facilitating further examination, and serves as a crucial basis for diagnosis; in some cases, a preliminary diagnosis can even be made based on this.
v Step 1 of diagnosing diseases:
v Complete data: Correct diagnosis is essential to avoid misdiagnosis (acute abdomen, ectopic pregnancy history).
v The “Five Fingers” theory: Proposed by American scholar Harey, it outlines the five processes of diagnosing diseases.
The thumb represents: Inquiry; The index finger represents: Physical examination; The middle finger represents: Close auxiliary examinations related to the disease; The ring finger represents: Auxiliary examinations to exclude the disease; The little finger represents: Routine laboratory tests.
3. Content and Methods of Inquiry
1. General Data:
Name Ethnicity Age Occupation Gender Admission Date Marital Status History Narrator Place of Origin Address
v Reminder:
(1) Marital Status: Use different questions based on age — Young people: Are you married? Middle-aged individuals: When did you get married?
(2) Occupation: Ask for specific occupation to rule out occupational diseases.
2. Chief Complaint:
(1) The most prominent signs at the time of consultation: Heart murmur, hypertension.
(2) The main symptoms: Shortness of breath, cough, edema.
Note: (1) Summarize in 1-2 sentences: Shortness of breath after activity for X years, worsened in X months.
(2) Patient narration, physician summarization (for complex medical histories).
(3) The timeline should be consistent with the present illness history.
3. History of Present Illness:
The most important part of the medical history, detailing the entire process after the onset, including occurrence, development, and evolution.
Includes:
(1) Onset situation:
Acute onset: Cerebral hemorrhage, angina, myocardial infarction, gastric perforation.
Gradual onset: Pulmonary tuberculosis, nephritis, tumors. Onset time:
Acute and critical conditions should be precise to minutes and hours; chronic diseases should be noted by year and month, the more specific, the better.
(2) Causes and triggers:
① Obvious causes of onset: Trauma, poisoning, infection.
② Triggers: Climate, environment, emotions.
③ Judging based on different diseases: Upper respiratory infection — pneumonia as a cause; heart failure, chronic nephritis exacerbation — triggers; excessive alcohol consumption, irritating foods — gastric bleeding and perforation.
(3) Characteristics of main symptoms:
① Location of main symptoms: Pain in the precordial area — angina; pain in the right upper abdomen — liver disease.
② Nature: Burning pain (gastritis); distending pain (liver); dull pain (gastric ulcer); colicky pain (heart, kidney stones).
③ Duration: Angina (paroxysmal) lasting (hepatitis, abscess).
④ Radiation: Cholecystitis (right shoulder), heart (left shoulder, upper limb).
⑤ Severity: Mild (gastritis), severe pain (intestinal perforation, gallstones).
⑥ Factors that worsen or relieve: Gastric ulcer, cold, irritating foods worsen, eating relieves.
(4) Development and evolution of the condition:
① Changes in main symptoms: Relief or worsening of precordial pain, frequency of occurrence, duration;lower limb edema → generalized edema, ascites.
② Appearance of new symptoms:
(5) Accompanying symptoms: Symptoms other than the main symptoms.
① Used for differential diagnosis: Low back pain, accompanied by frequent urination, urgency: urinary tract infection; accompanied by abdominal radiating pain, nausea, vomiting: urinary stones.
② Determine if there are complications: Chronic upper abdominal pain, black stools: ulcer bleeding; fever, cough, chest pain: pneumonia involving the pleura.
(6) Treatment history: Treatment received from onset to consultation.
① What examinations were done, and what were the results?
② What medications were used, dosages, duration, and effects?
③ For reference only, do not copy the original diagnosis.
(7) General condition during the course of the illness: Mental and physical state since onset, dietary and sleep patterns, bowel and bladder conditions.
① Estimate the severity of the condition: Uremia: poor appetite, decreased physical strength, sleep disturbances.
② Reference for auxiliary treatment: Severe cases require care, what kind of diet to adopt.
4. Past Medical History:
General health status, history of infectious diseases, vaccination history, allergy history, history of trauma, surgical history.
Note:① Past diseases that are the same as the current one: Include in the present illness history, such as rheumatic heart disease, hypertension, nephritis.② Past diseases that are different from the current one: Include in the past medical history, such as pneumonia and hypertension.③ When inquiring about infectious disease history, list specific diseases; patients may not be clear about whether certain diseases are infectious.
5. Systems Review:
① Includes: Symptoms from the respiratory, circulatory, digestive, urinary, hematological, endocrine, musculoskeletal, and nervous systems.
② Recollect any potentially omitted information.
③ Current symptoms should be marked during the inquiry and recorded in the present illness history.
④ Past symptoms should be documented with time and progression.
6. Personal History:
Place of birth, occupation, sexual history, smoking and drinking habits,sexual history: History of unprotected sexual intercourse.
7. Marital History: Age at marriage, health status of spouse.
8. Menstrual and Reproductive History::
Menarche, duration of each period (days), date of last menstruation (age at menopause), menstrual volume, dysmenorrhea, menstrual cycle, pregnancies × times, vaginal deliveries × births, miscarriages × times, preterm births × times, stillbirths × times, complications and conditions.
9. Family History:
(Note hereditary diseases and infectious diseases related to the patient’s current illness, inquire if there are similar diseases, avoid asking: Is there a hereditary disease?)Father (alive, ill, deceased, cause of death) Mother (alive, ill, deceased, cause of death) Siblings, children, and others.
4. Considerations in Inquiry:
1. Be friendly, maintain a proper demeanor, and avoid an interrogative style.
2. Avoid leading questions that guide the patient into a specific disease.
3. Avoid using medical jargon; use layman’s terms for continuous abdominal pain (medical records can use terminology).
4. Use language appropriate to the patient’s level of education.
5. Allow the patient to express themselves without interruption, but provide guidance.
6. In critical patients or if a critical condition arises during the inquiry, prioritize rescue.
5. Steps in Disease Diagnosis Evidence-Based
1. Data must be true, systematic, and complete.
(1) Chief complaint: Provides a broad and systematic overview of the disease.
(2) History of present illness: Provides the basis for diagnosing specific diseases.
(3) Physical examination: Look for abnormal signs.
(4) Laboratory data: Confirm initial judgments.
2. Integrate and analyze data: Summary of medical history.
(1) Be objective and respect the facts.
(2) The “unified” principle: If one disease can explain the situation, do not list multiple diseases.
(3) Consider common diseases first, then rare diseases.
(4) Consider organic diseases before functional diseases to avoid delaying treatment.
(5) Consider treatable diseases before irreversible diseases.
3. Make a preliminary diagnosis:
Acute, outpatient treatment; hospitalization for complex patients, observation, further examination, correction of diagnosis, final diagnosis, discharge diagnosis.