History taking

Habari Mwanafunzi! Welcome to the Art of Listening.

Welcome to the wards, my dear future colleague! You've spent two years mastering the intricate machinery of the human body. Now, you get to meet the person inside that body. Forget everything you think you know about being a doctor for a moment. Your most powerful diagnostic tool isn't the stethoscope around your neck or the textbook in your bag. It's your ability to listen.

A well-taken history is like being a detective, piecing together clues to solve a mystery. The patient is telling you their story, and your job is to listen with empathy and precision. It is said that over 80% of diagnoses are made from the history alone! So, let's sharpen this tool until it's as precise as a surgeon's scalpel.

The Sacred Structure: The Blueprint of a Patient's Story

Just like building a house, a good history needs a solid foundation and a logical structure. If you follow this flow, you will rarely miss a crucial detail. It keeps you organised, even when you're nervous (and it's okay to be nervous!).

 [ Start: Introduce & Build Rapport ]
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 [ 1. Bio-data (Demographics) ]
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 [ 2. Presenting Complaint (PC) ]
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 [ 3. History of Presenting Complaint (HPC) ]  <-- The Main Story!
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 [ 4. Systemic Review ]
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 [ 5. Past Medical & Surgical History ]
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 [ 6. Drug & Allergy History ]
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 [ 7. Family History ]
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 [ 8. Social History ]
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 [ End: Summarize & Thank Patient ]

Let's break down each part, the Kenyan way.

1. Bio-data: The 'Who'

This is the quick snapshot. It's more than just paperwork; it gives you immediate context.

• Name, Age, Sex
• Occupation: This is vital in Kenya! A boda boda rider in Nairobi might have back pain or RTA injuries. A farmer in Mwea might have signs of schistosomiasis. A corporate banker might have stress-related hypertension.
• Residence: Where they live tells you about potential endemic diseases. Someone from Kisumu or the Coast? Think malaria. Someone from a crowded settlement like Kibera? Think TB, typhoid.
• Marital Status & Religion: Can influence social support and certain health decisions.

2. Presenting Complaint (PC): The Headline

This is the main reason the patient came to the hospital, in their own words. Ask a simple, open-ended question: "Ni nini haswa kimekuleta hospitalini leo?" (What exactly brought you to the hospital today?).

Write it down verbatim. If they say "Kichwa kinapasuka," write "Severe headache," not "Cephalgia." It keeps the patient's voice at the centre of your notes.

3. History of Presenting Complaint (HPC): The Heart of the Matter

This is where you become a true detective. For any symptom, especially pain, use the powerful mnemonic SOCRATES.

• Site: "Where exactly is the pain? Can you point with one finger?"
• Onset: "When did it start? Did it come on suddenly (like a thunderclap) or gradually over days?"
• Character: "How would you describe it? Is it sharp like a kisu (knife)? Dull and aching? Burning like pili pili?"
• Radiation: "Does the pain move anywhere else? For chest pain, does it go to your jaw or left arm?"
• Associated Symptoms: "Apart from the cough, do you have fever, night sweats, or weight loss?" (Classic questions for TB).
• Timing: "Is it constant? Does it come and go (colicky)? Is it worse in the morning?"
• Exacerbating & Relieving Factors: "What makes it worse? Walking? Eating? What makes it better? Resting? Taking milk?"
• Severity: "On a scale of 1 to 10, where 1 is no pain and 10 is the worst pain you can imagine, what number is your pain?"

Image Suggestion:

A warm, empathetic photo of a Kenyan medical student sitting at the bedside of an elderly female patient in a public hospital ward. The student is leaning forward, listening intently, with a notebook open. The patient is gesturing to her chest, explaining her symptoms. The lighting is soft and natural, emphasizing the human connection.

4. Systemic Review: Casting a Wide Net

The body is connected. A problem in one area can cause symptoms in another. You must quickly ask one or two screening questions for each system to ensure you haven't missed anything.

• General: Fever, weight loss, night sweats, fatigue?
• Cardiovascular: Chest pain (maumivu ya kifua), palpitations, difficulty breathing when lying flat (orthopnea), leg swelling (edema)?
• Respiratory: Cough, sputum (what colour?), shortness of breath, wheezing?
• Gastrointestinal: Abdominal pain, nausea, vomiting, diarrhoea (kuhara), constipation?
• Genitourinary: Pain on urination, frequency, change in urine colour?
• Neurological: Headaches, dizziness, weakness, numbness?
• Musculoskeletal: Joint pain, muscle aches?

5. Past Medical & Surgical History (PMH): The Backstory

Has this happened before? What other medical battles has the patient fought?

• Ask about common chronic conditions in Kenya: "Umewahi ambiwa uko na pressure (Hypertension), sukari (Diabetes), pumu (Asthma), or HIV?"
• Previous TB: "Have you ever been treated for TB? Did you complete the medication?" This is critical.
• Previous surgeries or hospital admissions.
• For female patients (Obstetric/Gynae History): Ask about their pregnancies. A simple way is GPLAM.

G - Gravida: Total number of pregnancies
P - Parity: Number of births after 28 weeks
L - Live births: Number of currently living children
A - Abortions: Spontaneous or induced
M - Miscarriages

Example: A woman with 4 pregnancies, 3 live births, and 1 miscarriage.
G4 P3+1 L3 (Parity can be written as 3 carried to term + 1 pre-term)

6. Drug & Allergy History: What's Going In?

This is crucial! Don't just ask about prescribed medicine.

• Prescribed Meds: "Are you on any regular medication from a doctor?"
• Over-the-Counter (OTC): "Do you buy any medicines from the chemist, like Panadol or Piriton?"
• Herbal/Traditional Medicine: VERY IMPORTANT. Ask respectfully: "Kuna dawa za kienyeji ama miti shamba umekuwa ukitumia?" (Are there any traditional or herbal medicines you have been using?). These can have powerful effects and interact with hospital drugs.
• Allergies: "Are you allergic to any medication or food?"

7. Family History: The Genetic & Environmental Link

Some diseases run in families (genetics), and others cluster in households (environment/infection).

• Ask about first-degree relatives (parents, siblings, children).
• Focus on heritable conditions (Hypertension, Diabetes, Cancers) and infectious diseases (TB).

8. Social History: The World Outside the Ward

This section tells you about the patient as a person and reveals risks you'd otherwise miss. This is where you understand the context of their illness.

• Occupation & Home: We mentioned this in bio-data, but here you can go deeper. Who do they live with? What is their water source (risk of typhoid/cholera)? What is their sanitation like?
• Diet: "What did you eat for your meals yesterday?" This gives you a clue about their nutritional status. Is it balanced, or is it just ugali na sukuma every day?
• Habits (The 3 Vices):
  • Smoking: Don't just ask "Do you smoke?". Ask "How many sticks per day, and for how many years?" Then calculate the pack-years.

  
  Pack-Years = (Cigarettes per day / 20) x Years smoked
  
  Example: A man smoking 10 cigarettes daily for 20 years.
  (10 / 20) x 20 = 0.5 x 20 = 10 pack-years.
  (A high number is a major risk factor for COPD, lung cancer, etc.)
  

  • Alcohol: Quantify it. Don't just write "drinks alcohol." Ask what type (chang'aa, busaa, Tusker, Chrome) and how much.
  • Recreational Drugs: Including miraa (khat), bhang, etc. Be non-judgemental.
• Support System: "Who is at home to help you? Who do you rely on?" This is vital for planning their discharge.

A Story from the Ward

We once had a middle-aged man present with crushing chest pain, a classic heart attack picture. All tests were borderline. The consultant, a very wise doctor, went back to talk to him. He skipped the medical questions and just asked, "So, what's been happening in your life?" The man broke down. He had just lost his job, his child was sick, and he hadn't slept for a week from the stress. It was a severe panic attack mimicking a heart attack. The social history was the key that unlocked the entire case. Never, ever underestimate it.

Putting It All Together: Your First Clerkship

My friend, this looks like a lot, but it will become second nature. Start with a template, practice with your classmates, and be kind to yourself. Your first few histories might be clumsy, and that's perfectly fine. Every senior doctor you admire was once a nervous third-year, just like you.

Your goal is not just to collect data but to make a connection. Look the patient in the eye. Say "Pole sana" when they share something difficult. At the end, summarize what you've heard to ensure you got it right and thank them for sharing their story with you. "Asante sana kwa kunieleza shida yako."

Now, go on. Take a deep breath. Your first patient is waiting to tell you their story. Go and listen.