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01 History Taking

The document outlines the objectives and components of effective history taking in medical practice, emphasizing the importance of establishing rapport with patients and accurately gathering information. It details the distinction between symptoms and signs, the structure of patient history, and the specific areas to cover, including personal data, presenting complaints, and systemic reviews. Additionally, it highlights the significance of communication and respect in the doctor-patient relationship.

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Philip Majuch Mum
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11 views46 pages

01 History Taking

The document outlines the objectives and components of effective history taking in medical practice, emphasizing the importance of establishing rapport with patients and accurately gathering information. It details the distinction between symptoms and signs, the structure of patient history, and the specific areas to cover, including personal data, presenting complaints, and systemic reviews. Additionally, it highlights the significance of communication and respect in the doctor-patient relationship.

Uploaded by

Philip Majuch Mum
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd
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HISTORY

TAKING
OBJECTIVES FOR THESE
SESSIONS
By the end of these sessions we will be able to:

1. Differentiate between symptoms and signs.

2. Communicate with the patient and have full history.

3. Summarize the history.

4. Present the history to a senior.


OBJECTIVES OF HISTORY
TAKING:

GENERAL:
Obtain a professional rapport with the patient and gain his
confidence.

Obtain all relevant information which allows assessment of


the illness, and provisional diagnoses.

Obtain general information regarding the patient.

Understand the patient’s own ideas about his problems


SPECIFIC:
In taking a history or making an examination there are two
complementary aims

1. Obtain all possible information about a patient and his


illness (a database).

2. Solve the problem as to the diagnoses


If the relation between doctor and patient is broken there will be no out come
WHAT IS IMPORTANT
WHEN YOU START?
At the basis of all
medicine is clinical
competence. No amount
of knowledge will make
up for poor technique.
WHY PROPER HISTORY
Steps for history examination problem list
proper and
accurate differential diagnosis
investigation
diagnosis diagnose confirmation

treatment
BEING A DOCTOR IS NOT A PRIVILEGE
IT IS AN OBLIGATION
WHAT IS SYMPTOM
What the patient feel when his body machinery is not working
perfectly and it is the reason why they seek medical advice.

In presenting complain most be said in patient own words.


(yellowish discoloration of the eye)

But when analyzed use terminology. (jaundice)


WHAT IS SIGNS
It is the abnormal finding when conducting examination.

What the doctor observe on a patient.

Always presented in terminology.( jaundice)

Disease features are both symptoms and signs together.


Being ill and seeking others help is one of the most vulnerable
states of human being so be gentle
BEFORE WE START
1. Respect the patient.

2. Do not judge or blame the patient .

3. Trust the patient


COMPONENT OF
HISTORY TAKING
Personal Data
Presenting complaint
History of presenting illness
History

Systemic review
Past medical history
Family history
Drug history

Social history
Summery
CONTENT OF HISTORY
1. Personal data.
2. Presenting complaint.
3. History of presenting complaint.
4. Systemic review
5. Past medical history.
6. Family history.
7. Drug history
8. Social history
9. summery
PERSONAL DATA
1. Name (identification until the fourth name)
2. Age
3. Gender
4. Nationality
5. Residence current and origin.
6. Occupation and education degree
7. Tribe.
8. Marital status
9. Date of clerking.
PERSONAL DATA
Name

Age

Personal data Gender

Nationality

Residence

Occupation

Tribe

Marital status

Date of clerking

Phone number
PRESENTING
COMPLAINT:
The symptoms that made the patient seek medical advice.

Duration of those symptoms.

Mention the symptoms in their order of appearance.

Record in patient own words.


HISTORY OF
PRESENTING COMPLAINT
Begin by stating when the patient
was last perfectly well
Obtain a detailed description of
each symptom
With all symptoms obtain the following
details:
 duration

 onset—sudden or gradual

 what has happened since:

 constant or periodic

 frequency

 getting worse or better

 precipitating or relieving factors

 associated symptoms.

system involved
HISTORY
TAKING 2
COMPONENT OF
HISTORY TAKING
Personal Data
Presenting complaint
History of presenting illness

Systemic review
History

Past medical history


Family history
Drug history
Social history
Summery
SYSTEMIC REVIEW
General symptoms: fever, weight changes, General
well-being, fatigue, night sweats, sleeping disorders,
appetite.
Cardiopulmonary: cough, S.O.B, orthopnoea, palpitations,
oedema, haemoptysis, wheeze, chest pain, Black-outs
Gut or GIT : abdominal pain, difficult swallowing, nausea,
vomiting, bowel habit, haematemesis, melaena.
CONTINUE SYSTEMIC
REVIEW:
Genitourinary :urine( colour, amount, frequency),
incontinence, dysuria, haematuria, nocturia, hesitancy.
Female :Vaginal discharge, menses( frequency, regularity,
heavy or light, duration, dysmenorrhoea, LMP, number of
pregnancies and births, menarche, menopause.
Male: Impotence, loss of libido, penile discharge or itching.
CONTINUE SYSTEMIC
REVIEW:
Neurological: special senses( sight, hearing, smell, taste),
seizures, faints, headaches, numbness, limb weakness, poor
balance, speech problems, sphinctor disturbance, higher
functions.
Musculoskeletal: pain, stiffness, swelling of joints. Skin
rash or lesions, itching.
COMPONENT OF
HISTORY TAKING
Personal Data
Presenting complaint
History of presenting illness
Systemic review
History

Past medical history


Family history
Drug history
Social history
Summery
PAST MEDICAL HISTORY
Hospitalization.( operations( anaesthetic problems), blood
transfusion, hospital stay)
Similar condition.(disease progression)
Chronic illnesses.(DM, HTN, asthma, bronchitis, TB,
jaundice, rheumatic fever, heart disease, stroke, epilepsy,
peptic ulcer.
COMPONENT OF
HISTORY TAKING
Personal Data
Presenting complaint
History of presenting illness
Systemic review
History

Past medical history

Family history
Drug history
Social history
Summery
FAMILY HISTORY
Similar condition.
Chronic illnesses
Sudden death.
Inherited illnesses.
COMPONENT OF
HISTORY TAKING
Personal Data
Presenting complaint
History of presenting illness
Systemic review
History

Past medical history


Family history

Drug history
Social history
Summery
DRUG HISTORY
Current medication (prescribed or over the counter
including (Birth control drugs, erectile enhancement drugs).
Chronic medication.

Drug allergies.
(specify the symptoms)
COMPONENT OF
HISTORY TAKING
Personal Data
Presenting complaint
History of presenting illness
Systemic review
History

Past medical history


Family history
Drug history

Social history
Summery
SOCIAL HISTORY
Housing( how many rooms? how many people live in the
house?.
Sanitation.
Social habits: for how long, frequency, amount.
LASTLY BUT NOT LEAST
You need to know:
The patient’s ideas, concerns
and expectations
COMPONENT OF
HISTORY TAKING
Personal Data
Presenting complaint
History of presenting illness
Systemic review
History

Past medical history


Family history
Drug history
Social history
Summery
SUMMERY OF HISTORY:
Gender and age of the patient.
Chronic illnesses and medications if present.
Positive findings in history.
Important negatives in history.
HOW TO PRESENT HISTORY TO
YOUR SENIOR AND
COLLEAGUES?
You firstly start with personal data of your patient.
Then tell the story of presenting complain in the patient`s
own words
Tell the rest of the story in terminology.
Tell the story in order of the given theme.
WHAT TYPE OF
QUESTIONS
Direct questions in personal data.
Open ended focussed questions in presenting complaints.
Open ended questions in history of presenting illness.
Close ended questions in systemic review.( yes or No
questions).
Combination of direct and close ended questions in the
rest of the history.
PAIN:
• Site
• Onset
• Character: eg. Stabbing, burning, dull, heaviness,
colicky.
• Radiation
• Associated symptoms
• Timing : Duration, duration of attack, relation to day
time
• Exacerbating or Aggravating factors and Relieving
factors:
• Severity or Intensity: grading from 1 – 10
FEVER:
• mode of onset: acute, gradual
• associated rigors, chills or sweating
• Grade: low grade, high grade fever.
• Pattern: either changing in grade or steady at
same grade.
• Associated symptoms: Cough sputum, ear
pain or discharge, sore throat, burning
micturition.
• Pattern of fever: intermittent, remittent,
stepladder, continuous
EDEMA:
• Site: localized or generalized
• Association with pain
• Pitting or not
• Where it started first.
• Associated symptoms: shortness of breath,
jaundice, abdominal distension ( enlarged
liver)
• Relation to position
HEADACHE:
• Site: bilateral, unilateral, occipital, or frontal,
periorbital
• Radiation: eg. to the neck
• Character: throbbing, aching,
• Duration
• Severity: mild, moderate, or severe
• Continous or intermittent
• Aggravating factors: bright light, loud sounds, special
foods
• reliving factors: rest, analgesics ( paracetamol).
• onset and what time during the day.
WEIGHT LOSS:
• Sudden or gradual
• Planned or not
• Associated with loss of appetite or not.
• Other associated symptoms: fever, cough,
night sweats
ANY Q
UE S T IO N
S????
?

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