The document discusses the importance of history taking in medical diagnosis. It outlines the key steps in history taking including obtaining the patient's chief complaints, medical history, and performing a physical examination. A diagnosis is formed based on integrating the clinical history, physical examination findings, and test results. The document provides details on the various components of a patient's medical history and types of examinations and investigations that are part of the diagnostic process. The overall summary is that obtaining an accurate medical history is the first critical step in determining a patient's illness and establishing a diagnosis.

1. Sreenu Thalla
Assistant Professor
Department of Pharmacology

2. • It is a process by which information is gained by a physician by asking
specific questions to the patient with the aim of obtaining information
useful in formulating a diagnosis and providing medical care to the
patient
Importance of History Taking?
• Obtaining an accurate history is the critical first step in determining
the etiology of a patient's illness.
• Diagnosis in medicine is based on
 Clinical history
 Physical Examination
 Investigations

3. Personal Information
 Registration number
 Date
 Name
 Age
 Sex
 Address
 Occupation
 Marital Status
A large percentage of the time (70%), you will actually be able make
a diagnosis based on the history alone

4. Chief Complaints
• Should be recorded in patient’s own words.
• It is the reason for which the patient has come to the doctor.
Common Chief Complaints – Pain, Swelling
History of Present Illness
Past History
Family History
Personal History
“Always listen to the patient they might be
telling you the diagnosis”.

5.  Ensure consent has been gained.
 Maintain privacy and dignity.
 Ensure the patient is as comfortable as possible
 Summarise each stage of the history taking process.
 Involve the patient in the history taking process
Approach to history taking
Your look is important – Your dressing

6. Introduce your self and create a rapport

7. Be alert and pay full attention

8. Medical History
• The medical history includes the information about past & present
illness.
• All diseases suffered by patient should be recorded in chronological
order.
• Check list of medical history
 Anemia
 Bleeding disorders
 Cardio respiratory disorders
 Drug treatment and allergies
 Endocrine disorders
 Fits and faints
 Gastrointestinal disorders
 Hospital admissions and surgeries
 Infections
 Jaundice
 Kidney disease

9. General Examination
• Built, height ,gait, and posture.
• Pallor, icterus, clubbing, cyanosis, lymphadenopathy & edema.
• Vital signs like pulse, blood pressure, temperature, respiratory rate

11. Examination of Swelling
Inspection
• Site
• Size
• Colour
• Surface
• Shape
• Number
Palpation
• Tenderness
• Temperature
• Surface
• Consistency
• Fluctuation
• Fluid
• Thrill
• Pulsatility
• Translucency
• Fixity over Skin

12. Provisional Diagnosis
• It is also called tentative diagnosis or working diagnosis.
• It is formed after evaluating the case history & performing the
physical examination.
Differential Diagnosis
• The process of listing out of 2 or more diseases having similar signs
and symptoms of which only one could be attributed to the
patient’s suffering

13. • Haematological Investigations
• Histopathological investigation
• Radiological Investigations
Investigations
Heamatological Investigations
• RBC Count
• Heamatocrit
• Hb level
• WBC Count
• Differential Leukocyte Count
• Bleeding Time
• Clotting Time
• RBS
Histopathological Investigations
• Biopsy
• Excisional Biopsy
• Incisional Biopsy
• Intraosseous Biopsy
• Punch Biopsy
• Frozen Section Biopsy
• Exfoliative Cytology
• FNAC

14. Now you’ve got your information
• Give a Summary
• Ask if you’ve understood the information correctly
• Ask if there is any other information that the patient wants you to
know
• Advise what your plan would be
• Check with the patient that they are in agreement with your plan

15. Final diagnosis
• The final diagnosis can usually be reached following chronologic
organization and critical evaluation of the information obtained from
the
 Patient history
 Physical examination
 The result of radiological and laboratory examination.
 The diagnosis usually identifies the diagnosis for the
patient primary complaint first, with subsidiary diagnosis
of concurrent problems.