HISTORY TAKINGHISTORY TAKINGSoumya Ranjan ParidaSoumya Ranjan Parida

Basic B.Sc. Nursing 4Basic B.Sc. Nursing 4thth year yearSum Nursing CollegeSum Nursing College

DEFINATION• History is the record of medical events

that have already taken placed

• The most likely diagnosis in most cases can be reached by proper history

Basic information

• Name-Identification• Age • Sex –male-x-linked recessive disorder,

hemophillia -female-autoimmune disorder,SLE,

Thyroid disorder • Religion- Thallassemia(sindhi,muslim,) - G-6-PD def.(parsis)• Address- Malaria(Bikaner) - Brucellosis(Chattargarh)

PRESENTTING COMPLAINTS

• IN CHRONOLOGICAL ORDER e.g.- fever-5 days - headache-3 days - vomiting-3 days - convulsion-1day - loss of consciousness-12 hours

HISTORY OF PRESENT ILLNESS

FEVER-

COUGH-

•ONSET- acute or insidious•Duration•Character –continous/remittent/intermitent/stepladder/pelebstein•Severity•Chills and rigors•Associated symptoms- headache, burning micturation,rashes, relieved by medicine or not

•Onset•Duration•Frequency•Character- hacking,barking,paroxymal•Dry or Productive•Inhalation of foreign body

• VOMITING-

• DIARRHEA-

• Regurgitation of feed• Duration• Severity• Frequency• Blood/Bile stained• Associated symptoms• Symptoms of dehydration

• Severity• Duration• Frequency• Associated symptoms• Bulk• Consistansy• Content• Colour• Odour• Symptoms of dehydration

CONVULSION

PAIN ABDOMEN

• Time• Duration• Type• Frequency • Associated feature • Associated with fever/ear discharge/head trauma/indigenous medicine/recent vaccination

•Onset•Severity• Duration• Frequency• Site•Severity•Character•Radiation/Shifting/Referred• Aggravating/Relieving factor

HISTORY OF PAST ILLNESS

• History of similar illness in past• Details of perinatal history- Birth

asphyxia,Neonatal jaundice,Seizure• History of hospitilization• History of asthma,epilepsy,nephrotic

syndrome,measles,mumps,pertusis• Treatment history

OBSTETRIC HISTORY• Antenatal history

• Natal and Neonatal history

•ANC attended or not•Injection TT taken or not•Medication or illness during pregnency

•Mode and place of delivery•First cry after birth•Birth weight•Feeding difficulty•Jaundice•Seizure

FAMILY HISTORYFAMILY HISTORY

SOCIAL HISTORYSOCIAL HISTORY

History of similar illness in familyHistory of contactHistory of consanguinity among parents

Occupation,Education and income of parentsMother working or notHousing conditionHobbies and habbits of child

FEEDING HISTORY• Breast feeding

• Top feeding

• Weaning history

•Frequency,shedule,duration

•Age of stsrting•Dried or fresh milk•Dilution•Amount•Mode of feeding(bottle or spoon)

•Starting age•type

IMMUNIZATION STSTUSLook for BCG scar

History of previous immunizationNATIONAL IMMUNIZATION SCHEDULE

BENEFICIARY AGE VACCINE

Infants Birth BCG* and OPV**

6 weeks DPT&OPV

10weeks DPT&OPV

14 weeks DPT&OPV

9 monthsMeasles

vaccine ,OPV ,Vit A

18 months DPT&OPV(Booster dose),OPV

Children 5 years DT vaccine,OPV

10years Tetanus toxoid

16years Tetanus toxoid

THANKS