HISTORY TAKING FROM A PATIENT
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M K Alam MS,FRCSProfessor of Surgery
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PATIENT’S PROBLEM HOW TO SOLVE IT?
HISTORYCLINICAL EXAMINATIONCLINICAL DIAGNOSISINVESTIGATIONSFINAL DIAGNOSISTREATMENT
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IMPORTANT POINTS BEFORE HISTORY-TAKINGIntroduce yourselfExplain yourselfFull attentionTreat with respectLet patient talkGuide, not dictateNo leading questionNo short-cutsTry not to write and talk to the patient at the
same time
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Different parts of a historyPERSONAL DETAILSPRESENTING COMPLAINTHISTORY OF PRESENT ILLNESSSYSTEMIC INQUIRYPAST MEDICAL/SURGICAL HISTORYFAMILY HISTORYHISTORY OF MEDICATIONSSOCIAL HISTORYOTHER HISTORY
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PERSONAL DETAILSNAMEAGESEXNATIONALITYMARITAL STATUSOCCUPATION Record date of history taking and
examination
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PRESENTING COMPLAINT
What are you complaining of? (record in patient’s own words)
When more than one complain: (record in order of severity)
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HISTORY OF PRESENT ILLNESSFull details of the complaint or complaints.Get right back to the beginning of the trouble.Each complain- fully analyzed e.g., pain
Site Time and mode of onset ( sudden, gradual) Severity Nature (aching, burning, stabbing, constricting, throbbing) Progression Duration Aggravating/ relieving factors Radiation Cause
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SYSTEMIC INQUIRY of the involved or affected system
Example:
Chief complaint related to gastrointestinal system(GI)-
continue with the GIT inquiry.
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SYSTEMIC INQUIRY GASTRINTESTINAL SYSTEM
WeightAppetiteDysphagiaNauseaVomitingHeartburnHaematemesisFlatulence
JaundiceAbdominal painFat intoleranceConstipationDiarrhoeaMelaenaRectal bleedingStool
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SYSTEMIC INQUIRY RESPIRATORY SYSTEM
CoughSputumHemoptysisWheezeDyspnoeaChest painSmoking
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SYSTEMIC INQUIRY UROGENITAL SYSTEM
Loin painDysuriaNocturiaFrequencyHaematuriaUrinary streamIncontinenceUrethral discharge
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SYSTEMIC INQUIRY CARDIOVASCULAR SYSTEM
Angina (cardiac pain)Dyspnoea ( rest/ exercise)PalpitationsAnkle swellingClaudicationVaricose veins
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SYSTEMIC INQUIRY
Obstetric & Gynecology
LMPVaginal dischargeVaginal bleedingPregnancies
Nervous system
Headache FitsDepressionFacial/limb
weakness
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SYSTEMIC INQUIRY MUSCULOSKELETAL
Muscular painBone & Joint painSwelling of jointsLimitation of movementsWeakness
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SYSTEMIC INQUIRY METABOLIC/ENDOCRINE
Bruising/ bleedingSweatingThirstPruritusAlcoholWeight
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PAST MEDICAL/SURGICAL HISTORY
Rheumatic FeverTuberculosis/ AsthmaDiabetesJaundice Operations/ AccidentBlood transfusionMental illness
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FAMILY HISTORY
DiabetesHypertensionHeart diseaseMalignancyCause of death
Father/Mother/Siblings/Spouse/Children/Close relatives
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HISTORY OF MEDICATIONS
InsulinSteroidsNSAIDContraceptive pillsAntibioticsOthers
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SOCIAL HISTORYMarital statusOccupationTravel abroadAccommodationHabits ( smoking, alcohol )Dependent relatives
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OTHER HISTORYPsychiatric/ Emotional background
Allergies Food Drugs
Immunizations Tetanus Diphtheria Tuberculosis Hepatitis Others
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Review and analyse
More questions looking for clues?
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