A history in medicine is the initial step in making a diagnosis. History taking and its interpretation in otorhinolaryngology and head and neck surgery and in all medical and surgical branches are of the utmost important. The information gathered during history guides clinicians or students towards making a diagnosis. The examination’s ndings further helpful to reach a proper diagnosis and indicate which investigations may be appropriate to conrm it. The plan of management depends on correct diagnosis except extremely ill patients. A detailed history taking should be preceded by examination. The interactions during history taking help in building a strong doctor–patient relationship.

How to Obtain History—A clinician/student should allow a patient to tell the whole story. The clinician can ask questions to ll the gap in history. The students should listen the patient carefully and attentively and also make rough notes. A systematic approach to history taking and recording is crucial because a sick patient sometimes emphasises unnecessary facts and forgets to tell about very important disease-related symptoms.

History Taking—The structure of the history is similar to medical school teaching across the globe. The history includes details of the chief complaints, their exact nature and duration and

any other associated or predisposing factors. The past medical history of previous or concurrent medical conditions that are relevant to the current problem, or those that may affect the patient’s treatment or tness for anaesthesia, must be determined and noted.

1. Particulars of Patient The clinician/student should note the name, age, sex, religion, occupation and address of the patient.

2. History Proper—To obtain a proper history, a clinician/student should rst develop a good rapport with the patient and interview the patient in logical and sensible way. The patient should be listened carefully and interrupted only appropriately. These information should be interpreted correctly to make an accurate diagnosis.

The examiner should ask a new patient rst about the problems that force him/her to come to the hospital or meet the doctor by asking questions like: ‘What has been the trouble or problem recently?’ or ‘When were you last quite well?’ For a follow-up patient, some reference to the last visit is given, for example: ‘How have things been going since I saw you last?’ It’s been a week or a month since you last visited. This lets the patient know the clinician hasn’t forgotten him.

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2025 S. K. Kashyap, S. Sagar, Clinical Methods of Otorhinolaryngology, Skull Base & Head Neck Surgery, https://doi.org/10.1007/978-981-96-1765-4_1

1 General History Taking andGeneral Examination

A proper medical history should include the

following points:

• Chief Complaints—It is dened as the main complaints with which patient presents to hospital or doctor with duration. All the chief complaints are to be noted and presented in chronological order in patient’s own words. The technical or medical words should be avoided.

• History of Present Illness—It is a detailed narration of chief complaints in patient’s own language. In history of present illness, each of the chief complaints has to be talked about in detail with the patient. It consists of two parts; in the rst part, the patient should lead the discussion and tell whole story, whereas in the second part, the clinician/student should take more control and ask specic/leading questions, which helps to reach diagnosis. During writing the history of the presenting illness, detail of complaints should be placed in chronological order. If numerous systems are affected, the events should be placed in chronological order for each system.

The questions should be asked about most complaints are:

• Site of complaint

• Onset of complaint

• Character of complaint

• Radiation (if pain or discomfort)

• Aggravating and relieving factors

factors

• Timing

• Severity of complaint

– Site of symptoms—Clinician/student

should ask patient what is actual site of complaint, whether it is localised or diffuse. Some symptoms are not localized, for example, dizziness/vertigo, cough, shortness of breath and change of weight.

– Timing of symptoms—Patient should be

asked when a symptom started. For example, ask the patient ‘what was the rst thing you notice that was unusual or wrong’.

– Clinician/students should ask whether the

patient has had a similar illness in the past. It is often helpful to ask patients when they last felt entirely well.

– In a patient with long-standing symptoms,

ask why he or she decided to come and see the doctor at this time.

– Onset (mode of onset and pattern)

Sudden onset—If symptom came on rapidly, gradually or instantaneously. Gradual onset—If symptoms came slowly and spontaneously. Clinician should ask whether the symptom has been present continuously or intermittently. Determine if the symptom is getting worse or better since it onset. Find out what the patient was doing at the time the symptom began.

– Character of symptoms—The character of

symptoms can be different in two patients. For example, if the patient complains of dizziness, does this mean the room spins around (vertigo) or is it more a feeling of light-headedness? If patient is having pain, what is its character?

– Severity of symptoms—The subjective and

best way to assess severity of symptoms is to ask the patient whether the symptom interferes with normal activities or sleep. Severity can be graded from mild to very severe. Mild symptom can be ignored by the patient; moderate symptom cannot be ignored but does not interfere with daily activities; severe symptom interferes with daily activities, while very severe symptom markedly interferes with most activities. It is crucial not only to quantify accurately the severity of each symptom but also to remember that symptoms a patient considers mild may be very signicant. Severity of few symptoms may be graded differently for example:

Pain—Severity of pain is graded from scale 1 to 10. 1 is for no discomfort and 10 is for unbearable pain. Shortness of breath—The severity of shortness of breath can be quantied

1.1 General History Taking and Examination

more precisely; for example, shortness of breath on exertion occurring after walking 10 m on at ground is more severe than shortness of breath occurring after walking 90m up a hill. Central chest pain—Chest pain due to angina occurring at rest is more signicant than angina occurring while running 90m to catch a bus.

– Radiation of symptoms—This is dened as

symptoms radiates from one part of body to other. This is usually associated with pain like tooth pain radiated to the head, sinus pain radiated to head, chest pain radiated to arm or axilla, neck pain radiated to arm and back pain radiated to leg.

– Alleviating/relieving factors

Patients should be asked whether anything makes the symptom better. For example, the pain of pericarditis may be relieved when a patient sits up. Have analgesic medications been used to control the pain? Have narcotics been required? Pressing ipsilateral internal jugular vein relieved the tinnitus; headache relieved by taking rest by evening.

– Aggravating/exacerbating factors

Patient should be asked whether anything makes the pain or symptom worse. For example: The slightest movement may exacerbate the abdominal pain of peritonitis, chewing may increase the pain in tympanic membrane (TM) joint disorders and TM joint movement may increase pain in otitis externa.

– Associated symptoms—An attempt is

made to nd out any associated symptoms with presenting complaints by asking leading question. For example, an association of ipsilateral retroorbital pain with ear discharge and earache suggests petrositis. A single symptom may provide the clue that leads to the correct diagnosis, while the combination of characteristic symptoms most reliably suggests the correct diagnosis.

– Positive history—It is dened as presence

of symptoms that are supposed to be pres-

ent with the present complaint. Positive history suggests the presence of predisposing factors or complications, for example, a history of nasal obstruction in the case of CSOM and suppurative otitis media (SOM).

– Negative history—It is defined as

enquiring about the presence of symptoms that are supposed to be present with the present complaint but are absent. A negative answer here is as important as a positive one.

– Leading question—It is dened as the

direct question asked by examiners or students which lead to diagnosis and its answer is usually yes or no. These questions to be asked to patients who do not give a cohesive history. The answers to these questions should be cross-veried.

• Past history—It is a history about past chronic diseases like tuberculosis, diabetes mellitus, hypertension, bronchial asthma and episode of similar disease. Students/clinicians should ask the patient whether he or she has had any history of serious illnesses, operations or admissions to hospital in the past. Previous illnesses or operations may have a direct bearing on the current health of the patient.

• Personal history—In personal history, clini- cian should include economic, social, domestic and occupational status of the patient. For example, ask about residence, level of education, migration, smoking, diet of patient, addiction, overseas travel and marital status. Recent migrants may have been exposed to infectious diseases like tuberculosis; ethnic background is important in some diseases, such as thalassaemia and sickle cell anaemia.

• Family history—In this part of history, the clinician should enquire about the disease which runs in families. For example, ischaemic heart disease that has developed at a young age in parents or siblings is a major risk factor for ischaemic heart disease in the offspring. Similarly, various malignancies, such as breast cancer, can also be signicant risk factors. Ask about any history of a similar illness in the family and sibling and the economic status of family.

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Contents

1.1 General History Taking and Examination