History taking

1. HISTORY TAKINGHISTORY TAKING
Soumya Ranjan ParidaSoumya Ranjan Parida
Basic B.Sc. Nursing 4Basic B.Sc. Nursing 4thth
yearyear
Sum Nursing CollegeSum Nursing College

2. 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

3. 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)

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

5. 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

6. • 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

7. 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

8. 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

9. 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

10. FAMILY HISTORYFAMILY HISTORY
SOCIAL HISTORYSOCIAL HISTORY
History of similar illness in family
History of contact
History of consanguinity among parents
Occupation,Education and income of parents
Mother working or not
Housing condition
Hobbies and habbits of child

11. 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

12. IMMUNIZATION STSTUS
Look for BCG scar
History of previous immunization
NATIONAL IMMUNIZATION SCHEDULE
BENEFICIARY AGE VACCINE
Infants Birth BCG* and OPV**
6 weeks DPT&OPV
10weeks DPT&OPV
14 weeks DPT&OPV
9 months
Measles
vaccine
,OPV ,Vit A
18 months DPT&OPV(Booster
dose),OPV
Children 5 years DT vaccine,OPV
10years Tetanus toxoid
16years Tetanus toxoid

13. THANKS