This is the foundation of the diagnosis of the patient's condition. A good history taking is very important in finding out what has happened and why it has happened.

1. Medical History Taking
Kavya Liyanage

2. Why medical history taking is important?
▪ Patients do not come to the doctor with the diagnosis, but with
symptoms.
▪ In order to diagnose what the patient has, we need to get a good
relevance history of the patient.
▪ Also, history taking helps to find the cause for the patient’s condition.

3. Main Components of History Taking
▪ Introduction
▪ Presenting complaint
▪ History of presenting complaint
▪ Past medical history
▪ Past surgical history
▪ Drug history and allergies
▪ Family history
▪ Social history

4. Introduction
▪ Name
▪ Age
▪ Occupation
▪ Residence

5. Presenting complaint
▪ This should be in the patient’s words.
▪ Symptoms and their duration

6. History of presenting complaint
▪ Onset, nature, course and duration of each symptom
▪ When describing a pain, characteristics of pain is described as
SOCRATES
– Site
– Onset
– Character
– Radiation
– Associated features
– Timing (duration, course, pattern)
– Exacerbating and relieving factors
– Severity

7. Past medical history
▪ Medical details related to the current complaint
▪ Important negatives also should be mentioned

8. Past surgical history
▪ Previous surgical procedures that the patient had undergone.
▪ The type of anaesthesia used and any complications

9. Drug history and allergies
▪ Significant drugs that the patient has been using
▪ Allergies

10. Family history
▪ Family history about relevant diseases that can be transmitted
genetically to the patient

11. Social history
▪ Whether the type of living of the patient has an impact on the patient’s
condition
▪ Occupation
▪ Marital status
▪ Living circumstances
▪ Smoking
▪ Alcohol
▪ Illicit drug use
▪ Family support

12. Thank You!