History Taking

Thing to remember: 1) Stand on the right side of the patient with good confidence .

2) Introduce yourself as a medical student not as a doctor . ( you may face difficult question ).

3) Talk the patient gently with clear comprehensible words .

4) Remember don’t hurt the patient in your speak & touch .

In General any history should contain the following in consequence:

1. Introductory information (patient ID)

2. Presenting complaint (Chief)

3. History of presenting complaint (illness)

4. past medical history

5. past surgical history

6. Gynecological history

7. Family history

8. Social history

9. Drug history

10. Systems review

1. Introductory information (patient ID)

You should remember the Famous player ^MARADONA^

SO we ask about:

Marital status

Age

Religion

Address

Date of admission

Occupation

Name

ABO & RH

Sex

When you read the patient ID you should say the following:

I wanna to present my patient who’s name………….,age…………..years,sex……..

Religion………………,martial state………….,live in……………..,work as………….

Blood group……………,admitted to hospital at…………..

2. Presenting complaint (Chief)

The main cause that made the patient get hospital & here you should avoid the

medical terms. It should be a symptom not a sign.

Or What is the problem that brought you to hospital [record in pt.’s own words?]

Example of common chief complaint (should read carefully)

Diarrhea = frequent bowel motion

Constipation = infrequent bowel motion

Vomiting = explosion of gastric content or (same term )

Fever = increase body temp.

Dysphagia = difficulty in swallowing

Dyspnea = shortness of breath

Fit = abnormal involuntary movement

Headache = same term

Pain = same term

Edema = swelling of part of the body

Jaundice = yellow discoloration of the skin & sclera

Hematemesis = blood on vomitus

Cyanosis = bluish discoloration of the skin & sclera

Weakness = same term

Mass = same term

Hemoptysis = blood in sputum

When you read the Chief Complain you should say:

After reaching (admitted to hospital at…………..) due to………………..

[admitted to hospital at…………..,due to…………….]

3. History of presenting complaint (illness) Is the main part of history . Here you should remember two words

^OPERATES^ and ^SWAD^: Onset of complaint

Progress of complaint

Exacerbating factors

Relieving factors

Associated symptoms

Timing

Episodes of being symptom-free

Relevant Systemic and general inquiry can be added here Then Does the disease affect (Disease severity):

Sleep

Weight

Appetite

Daily activity Also you should talk about: the status of the patient after admission & receiving therapy, is he /she feeling well or not?

When you read the present illness you should say:

1) If the patient has a chronic condition previously such as ( diabetes , hypertension

…) say : the patient is a known case of …… for duration presented with …..

2) IF not say The condition started when the patient ( suddenly or gradually )

complained of ……

4. past medical history

This part include the chronic disease. Here you should

remember ^MJ THREADS^:

MI Jaundice TB HTN ["Anyone told you, you have high BP?"] Rheumatic fever

Epilepsy Asthma Diabetes Stroke

5. past surgical history

Any operation in the past.(name of operation,date,post-oprative complication) Blood transfusion history (bint , date ,complication)

6. Gynecological history

1) Menarche 2) Menstrual cycle [Regular or not, duration, bleeding heavy or not]

7. Family history

1)The current complaint in parents/ siblings: 2) Are your father, mother, brothers, sisters alive? - If they have died, at what age did he/she/they die? What did he/she/they die of? 3)Do they have any current illnesses? 4)Do any illnesses run in your family?

8. Social history

1) Smoker or not ? 2) Alcoholic or not ? 3) Any special habit ( bird collector ) . 4) Economic state . 5) Living in large or small place ? 6) Water supplementation ( tab , river water )? 7) In rural urban place . 8) Is there any domestic animal ?

9. Drug history

1)long term drugs 2)drug allergy[pencilin,sulph,cephalosporin]

10. Systems review CARDIOVASCULAR

Chest pain/angina

Shortness of breath (including on exercise)

Orthopnoea

Paroxysmal nocturnal dyspnoea

Palpitations

Ankle swelling

RESPIRATORY

Chest pain

Shortness of breath/wheeze

Cough/sputum/haemoptysis

Exercise tolerance

GASTROINTESTINAL

Appetite/weight loss

Dysphagia

Nausea/vomiting/haematemesis

Indigestion/heart burn

Jaundice

Abdominal pain

Bowels: change/constipation/diarrhoea/

description of stool/blood/mucus/flatus

MUSCULOSKELETAL

Pain/swelling/stiffness – muscles/joints/back

Restriction of movement or function

Able to wash and dress without difficulty

Able to climb up and down stairs

GENITO-URINARY

Frequency/dysuria/nocturia/polyuria/oliguria

Haematuria

Incontinence/urgency

CENTRAL NERVOUS SYSTEM

Headaches

Fits/faints/loss of consciousness

Dizziness

Vision- diplopia

Weakness

Numbness/tingling

Loss of memory/personality change

Anxiety/depression

ENDOCRINE

Menstrual abnormalities

Hirsutism/alopecia

Polyuria/polydipsia

Amount of sweating