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His | history module | 002
1. History taking provides vital information to arrive at a diagnosis in over 70% of cases by allowing the patient to describe their illness and systematically inquiring about their medical history, presenting complaints, past illnesses, habits, and family history. 2. It is important to build rapport with the patient, have them describe their illness chronologically without interruption, then prompt them for details in key areas before making a systematic inquiry about each body system. 3. A thorough history should explore the patient's presenting complaints, history of present illness, investigation and treatment details, past medical history, personal history, and family history in order to understand how their illness started and progressed and arrive at the most likely diagnostic possibilities based on
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His | history module | 002
- 1. TIPS ON HISTORY TAKING Prof.Dr. Aswinikumar Surendran. MD Professor of Medicine, MCH TrivandrumModule No: 2
- 2. HISTORY TAKING Story ofthe illness as narrated by the patient Student or doctor elicits all the details Then writes down in a specific format What is meant by history taking?
- 3. HISTORY It gives youa diagnosis in >70% of cases Then investigate to confirm and localise Then treat for a cure/symptom relief Why is history taking very important?
- 4. DIAGNOSIS FROM HISTORY Migraine,an important cause of headache Diagnosis arrived at from history alone No investigations needed - simply treat Give an example?
- 5. DIAGNOSIS Dia= Disease Gnosis =Knowledge Diagnosis = Knowledge about the disease What is meant by “diagnosis”?
- 6. HISTORY TAKING 10-15' ina long case in examination 5-10' in the outpatient department <5' in an emergency department How much time to allot for history taking?
- 7. GREET THE PATIENT Say“Hello” or “ Good Morning” Introduce yourself as a medical student Get permission for interview/examination First of all
- 8. BUILD UP ARAPPORT Common place of residence Common nature of job of relatives Common area of interest like computers Find some way
- 9. TALK TO THEPATIENT DIRECT Patient - best person to describe his illness Only he can, describe sequence of events And tell the severity and important ones Not to the relative or bystander
- 10. NEED NOT TALKTO BYSTANDERS Project their own ideas about the case Give importance to details of their choice Even interfere in interview /examination May be unrelated/uneducated/employed
- 11. POSITION PATIENT CORRECTLY Patientlying comfortably Yourself standing on right side Throughout the period of interview Make yourself comfortable
- 12. NO NOTE-TAKING DURINGHISTORY Gets disinterested; even walk away Instead use only small spiral books Just note down forgettable things Not in large note books in any case
- 13. CASE SHEET Sit atsome other place Write legibly and beautifully To read, understand and refer later Better written later
- 14. HOW TO TAKEHISTORY Name, age, sex Residence, occupation, nature of work IP number, Date of admission First collect the patient details
- 15. PRESENTING COMPLAINTS Major complaintsof the patient For which he has approached doctor Or admitted to the hospital this time What is meant by presenting complaints?
- 16. PRESENTING COMPLAINTS To notekey problems of the patient In one look at the case sheet In chronological order What is the purpose?
- 17. PRESENTING COMPLAINTS Fever, cough,hemoptysis Abd pain, vomiting, loose stools Weakness of upper and lower limbs Only words or phrases
- 18. PRESENTING COMPLAINTS Fever –4 days Cough – 3 days Hemoptysis – 1 day Put in a chronological order
- 19. HISTORY OF PRESENTILLNESS Whole story as narrated by patient So be a “good listener” to the story Later become a good “story teller” Not the “h/o presenting complaints”
- 20. TAKE HISTORY IN3 PHASES First phase: Only narration by patient 2nd phase: Prompt to detail & expand 3rd phase: Make a systematic enquiry Listen, prompt, enquire
- 21. FIRST PHASE When didthe first symptom start Ask to tell the whole story till to date Do not interrupt, allow him to finish Last time apparently normal
- 22. SECOND PHASE Fever –ask for details of fever Cough – ask to detail sputum Hempoptysis – Assess the quantity Find out details of each
- 23. THIRD PHASE Ask forcardinal symptoms Select a list from each system Find out each system is affected/not Systematic enquiry
- 24. SYSTEMATIC ENQUIRY CVS: Chestpain, dyspnoea, palpitation, syncope RS: Chest pain, cough, dyspnoea, hemoptysis GIT: Vomiting, loose stools, abdominal pain System wise
- 25. SYSTEMATIC ENQUIRY CNS: Headache,weakness, numbness, ataxia MSS: Muscle pain, arthralgia, neuralgia HES: Pallor, fatigue, bleedingtendencies System wise
- 26. INVESTIGATION DETAILS Details ofall investigations Done elsewhere in other clinics Done after admission to this hospital Make a detailed enquiry
- 27. TREATMENT DETAILS Ask forall treatment received Both in outside hospitals and inside Tolerance to drugs and side effects Make a detailed enquiry
- 28. H/O PAST ILLNESSES Anysimilar illnesses in the past Illnesses requiring prolonged rest List: DM2/HTN/CAD/PTB/IH All illnesses in past
- 29. PERSONAL HISTORY Appetite, lossor gain in weight Veg/non-veg, food for the day Bladder/bowel/sexual habits Regarding habits/what change occurred?
- 30. FAMILY HISTORY Father/mother/brothers/sisters Wife andchildren Similar 3 step approach All illnesses in members of family
- 31. SUMMARY OF NATURALHISTORY How the illness started? How it progressed then? What is the state now? Put it in a nutshell
- 32. DIAGNOSTIC POSSIBILITIES Give 4-5broad diagnosis? Give points in favour of diagnosis? Give points against diagnosis? From history alone