History taking

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History taking

  1. 1. INTRODUCTION TO MEDICINE HISTORY TAKING Dr. Wasim Uddin Consultant Physician POF Hospital Wah Cantt
  2. 2. What is History? • Getting to know the patient. • Why has he come to doctor/hospital? • Getting as much detail about his complaints as possible.
  3. 3. How to Start? • Introduce yourself. • Take patients permission. • Stand on Patient’s Rt. Side of bed. • Listen carefully.
  4. 4. Patient’s Details • Name • Age • Sex • Address • Occupation • Date of Admission
  5. 5. Presenting Complaints • Complaints which has brought the patient to the doctor. • Enumerate them in a chronological order. • Mention time. • Use simple descriptive terms.
  6. 6. Example • • • • Name Age Sex Address : : : : ABC 60 years Male WMC • Occupation : Driver • Presenting Complaints: – Fever : – Cough : – Blood in sputum : 3 Months 6 wks. 3 days
  7. 7. History of Present Illness • Detail about each of the presenting complaints. • Use simple language. • Avoid using diagnosis. • Do not ask leading questions.
  8. 8. History of Present Illness • Onset of each complaint. • Progress and course of complaint. • Aggravating or relieving factor. • Associated symptoms.
  9. 9. History of Present Illness - Example • Pain – Onset – Site – Character – Radiation – Course – Aggravating/relieving factors – Associated symptoms
  10. 10. History of Present Illness • Facilitate patients by simple questions. • Try to stop unnecessary details. • Be ready for any emotional outburst. • Never argue – postpone interview if needed.
  11. 11. Past History • Ask about significant relevant past medical history. • Cut out on unnecessary detail.
  12. 12. Treatment History • Prescription drugs. • Other medicines. • Ask for any drug allergies. • Treatment compliance.
  13. 13. Family History • Relevant family history. • Open ended questions. • Know about genetics. • Ask about other household members.
  14. 14. Social History • Occupation. • Income – Other family support. • Type of house. • Personal habits – Smoking, drugs. • Travel History.
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