History Taking

Why do we take history from the patient?

What would happen if we do not make a diagnosis?

or if we made the wrong diagnosis?

How do we take history?

Set up of history taking

In the outpatient clinicIn the inpatient clinic

Components of the History

The present complaintThe history of the present complaintRemaining questions of abnormal systemReview of systemsPast medical history

Past surgical historyDrug history

Immunizations

Family historySocial history & habits

ALWAYS

INTRODUCE YOURSELF TO THE PATIENT AND EXPLAIN TO HIM OR HER WHAT YOU ARE GOING TO DO. GET A CHAPERON WHEN YOU INTERVIEW A FEMALE PATIENT.

ALWAYS RECORD PATIENT’S

NameAgeSexMarital statusOccupationAddressDate of interview

1-Present complaint

In patient’s own words with duration.“What are you complaining of?”“What is the problem?”“What is the matter?”

2-History of the present complaint

EXAMPLE: ABDOMINAL PAINSiteTime and mode of onsetNatureDurationSeverity

RadiationProgression/endRelieving factorsExacerbating factorsCause

3-Remaining questions of abnormal system

Is it time to make a provisional diagnosis?

What is a diagnosis?

Diagnosis

Any diagnosis consists of Anatomical part + Pathological

partExamples:

Breast cancerPeptic ulcerFracture femur

Differential diagnosis or working diagnosis

Most likely why?Less likely why?Least likely why?

4-Review of systems

The Gastro-intestinal systemThe Respiratory systemThe Cardiovascular systemThe Urogenital systemThe Nervous systemThe Musculoskeletal system

Gastro-intestinal system

AppetiteDietWeightTeeth and tasteSwallowingRegurgitationFatulance

HeartburnVomitingHaematemesisAbdominal PAINAbdominal distensionDefecationChange of color of skin

The Respiratory system

CoughSputumHaemoptysisDyspnoeaOrthopnoeaChest pain

The Cardiovascular system

CHEST PAINDyspnoeaOrthopnoeaPalpitationsCough and sputumDizziness and headacheAnkle swellingPeripheral vascular symptoms

The Urogenital system

PainOedemaThirstMicturitionUrine

Scrotum and urethraMenstruationPregnanciesBreastsSecondary sex characteristics

The Nervous system

Mental stateConscious levelFitsTIAS= transient ischemic attacksLoss of sensationsParaesthesiae (pins and needles)

The musculoskeletal system

PainSwellingLimitation of movements of any joint

5-Past medical history

Any hospitalizationTB = TuberculosisDM = Diabetes mellitusAsthmaRheumatic feverContact with patients with hepatitis or aids

6-Past surgical history

Previous operationsBlood transfusionAny complications with anesthesiaBleeding tendencies

7-Drug history

SteroidsInsulinAntihypertensive drugsHormone replacement therapy

8-Immunizations

DPT = diphtheria, pertussus, tetanusMeaslesMumpsRubellaPoliomyelitisTBSmallpoxTyphoid

9-Family history

Health and age or cause of death of patient’s parents ,brothers and sisters

10-Social history & habits

Marital statusHazards of occupationSocial status- type of residenceTravel abroad-datesSmokeDrinksAny unusual?

Summary

Patient’s name, age and sex.Complaint and the most important positive characteristics of his/her complaintThe most important negative features of his complaint.

Analysis of the differential diagnosis

Review the list you made earlier

What have we gained from the history taking?

To make a diagnosisTo formulate a complete picture about this patient which will enable you to plan his or her management

THANK YOU