History-Taking is EVERYTHING: A First-Timer’s Guide to Case Presentations

Being a first-timer in making a case presentation is really stressful. You honestly won’t know where or how to begin. Like me, you’ll probably overthink a lot—afraid to miss important details, unsure about how deep your assessment should go, and scared to face your clinical instructors. But don’t worry, it’s all part of the learning process.

One thing I can’t stress enough: history-taking is everything. It’s the foundation of your case. If you don’t get enough details from your patient or their family, your case will feel incomplete, no matter how much effort you put into the rest.

In my experience, especially during our CHN (Community Health Nursing) case presentation, we were even asked things as specific as how many plates and utensils the family had or if the income from their sari-sari store was active or passive. These questions may seem small, but they give deep insight into the family’s lifestyle—which is essential in nursing care planning.

Practical Tips for Better, Deeper History-Taking

1. Don’t Just Settle for Yes or No Questions

Avoid closed questions. Instead, ask open-ended ones to gather richer, more detailed data. Start broad, then narrow it down.

Instead of:

• “May ubo po ba kayo?”

Try:

• “Kailan niyo po unang napansin ang ubo?”
• “Paano po ‘yung tunog ng ubo niya? Parang may plema po ba?”
• “Sa palagay niyo po, ano ang nakapagpalala?”

Use the 8 characteristics of symptoms (OLD CARTS):

• Onset
• Location
• Duration
• Character
• Aggravating/Relieving factors
• Radiation
• Timing
• Severity

2. Listen Actively

Patients don’t always give you the right info right away. Pay attention to their stories and body language. These often lead to more meaningful follow-up questions.

3. Clarify and Confirm

If something sounds vague or confusing, don’t assume—ask! Confirm all important details, especially:

• Medications (brand, dosage, etc)
• Past illnesses
• Habits

4. Go Beyond Clinical—Assess the Social Aspect

Ask about their:

• Living conditions
• Family structure
• Source of income
• Education
• Access to health services

These non-clinical factors affect how well patients follow advice or recover.

5. Be Respectful and Empathetic

Build rapport first. Patients open up when they feel respected and heard.

Instead of:

• “May sapat po ba kayong pera?”

Say:

• “May mga panahon po ba na kulang ang kita para sa pagkain o gamot?”

Use a gentle tone and non-judgmental language, especially for sensitive questions.

6. Take Notes Properly

Write everything clearly and completely. Avoid messy or shorthand notes that might confuse you later during encoding or discussion.

7. Prepare a Good Guide or Checklist

Before you converse with your patient, prepare a detailed checklist or interview guide. This helps you stay focused and prevents you from missing essential information during the data collection phase. When you’re nervous or under time pressure, it’s easy to forget important areas, so having a structure in place is a lifesaver.

Suggested Categories for Your Checklist:

• Chief Complaint (CC): What brought the patient to the hospital or health center?
• History of Present Illness (HPI): When did it start? What are the symptoms? Is it getting better or worse? Apply the OLD CARTS format (Onset, Location, Duration, Character, Aggravating/Relieving factors, Radiation, Timing, Severity).
• Past Medical and Surgical History: Any known illnesses, medications, allergies, or previous operations?
• Family History: Any hereditary diseases or illnesses that run in the family?
• Lifestyle and Habits: Sleeping patterns, eating habits, vices (smoking, alcohol), daily activities, hygiene, etc.
• Environmental and Socioeconomic Background: Living conditions, household members, occupation, income, education, access to clean water, number of utensils/plates, etc.

Formulate Your Questions in Advance

Don’t go in blind—write down your questions beforehand, including potential follow-up questions. For example:

• Main Question: “Ano po ang karaniwang kinakain niyo sa isang araw?”
  • Follow-up: “Ilang beses po kayo kumakain sa isang araw?”
  • Follow-up: “Paano po kayo naghahanda ng pagkain? May ref po ba kayo?”

Preparing this way makes you more confident and helps ensure smooth, natural flow in your conversation with the patient. You won’t have to pause too long thinking of what to ask next, and you’ll appear more professional and competent.

Consult Your Clinical Instructors (CIs)

Before you interview your patient, consult your guide with your CI. They know what kind of data clinical instructors typically look for during case presentations, and they can give you suggestions to improve your questions or highlight areas you might be missing.

• They might say, “Try to explore the hygiene practices more,” or
• “Include a question about who takes care of the patient at home.”

Their input can make the difference between a surface-level and a comprehensive case study. It also shows initiative and helps build trust with your CI.

Bonus Tip: Communicate with Your Groupmates

You’re not doing this alone. Your groupmates are your teammates for the whole semester, so:

• Communicate clearly
• Share tasks fairly
• Clarify any misunderstandings
• Build a good friendship and support system

Trust me when things get overwhelming, having a solid support system makes a big difference, trust me!.