Medicine and Healthcare

1. History Taking
Jimcale M Xamari

2. History taking
• It is the Foundation pillar of patient’s
management.
• It should be recorded in patient’s own
language without involving too many technical
terms.

3. Introduction
• Introduce your self to the patient.
• Tell the patient your name, title and what you
want to do.
• Verbal consent: the patient should accept you
before starting the interview.

4. Patient Information
• Record the patent’s:
1. Name
2. Age
3. Gender
4. Marital Status
5. Occupation
6. Address

5. Chief Complaint
• Chief complaints should be noted down in
chronological order with the most important
complaint on the top with its duration.
• E.g: Abdominal pain for 3 days.

6. History of Present Illness
• HPI should elaborate all the presenting
complaints one by one in more detail.
• If the patient cannot give an appropriate
history, then help of immediate relative
should be sought.

7. HPI
• Socrates:
1. Site
2. Onset
3. Character
4. Radiation
5. Associated symptoms
6. Time
7. Exacerbating/Relieving Factors
8. Severity

8. Past Medical History
• We must outline the details of any past history of:
1. Illnesses
2. Hospitalizations
3. Surgical Operations
4. Accidents
5. Blood Transfusions
• This may or may not be related to the current illness.
Chronic illnesses should also be noted.

9. Family History
• It is important to note down any history of
illnesses in the family, i.e. parents, uncles,
aunts, brothers and sisters especially in context
with the current illness.
• The health status of the parents and the cause
of death.

10. Menstrual History
• Important to ask from all female patients.
1. The onset of menarche
2. The regularity of menstrual cycle
3. The quantity of blood loss per menstrual cycle
4. The age of menopause
5. Then any dysfunctional uterine bleeding
6. Ask about use of contraceptive pills

11. Drug History
• Any known Allergies
• Drugs for chronic disease
• Any drugs for the current condition.

12. Social History
• Work and income
• Whether living with family or alone
• Marital Status and number of children
• Ask about alcohol, Kat, Smoking and history
of substance or drug abuse.
• if the patient is smoker, ask number of packs
per day and how many years of smoking.

13. Respiratory System
1. Cough — Dry or productive
2. Sputum — Color, amount, blood stained, time
of the day
3. Dyspnea
4. Chest pain
5. Fever
6. Wheezing.

14. Cardiovascular System
1. Breathlessness: at rest, on exertion
2. Chest pain (Socrates)
3. Palpitations
4. Cough
5. Abdominal pain
6. Oliguria
7. Oedema
8. Syncope
9. Fever

15. Gastrointestinal System
• Pain
• Appetite
• Vomiting
• Dysphagia
• Flatulence
• Jaundice
• Heart burn
• Diarrhoea
• Constipation
• Malena
• Distension.

16. Urogenital System
1. Dysuria
2. Polyuria
3. Frequency, urgency, hesitancy
4. Haematuria, dribbling, urethral discharge,
5. Oliguria
6. Anuria
7. Lower abdominal pain
8. Fever with chills.

17. Hematological System
• Pallor
• Weakness
• Lack of concentration
• Dyspnoea
• Ankle oedema
• Easy bruisability
• Skin lesions
• Nose bleeding
• Gum bleeding
• Glandular enlargement
• Bone pains
• Fever with infections

18. Central Nervous System (CNS)
1. Headache
2. Sleep disturbances
3. Vomiting
4. Visual disturbance
5. Convulsions
6. Dizziness
7. Speech, memory
8. Sense of smell, vision, hearing, gustation (taste)

19. Endocrine System
1. Weight loss or gain
2. Polydipsia
3. Hair loss
4. Pigmentation
5. Striae
6. Headaches
7. Voice changes