History Taking. Why do we take history from the patient?
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Transcript of History Taking. Why do we take history from the patient?
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