classic history taking

1. 786
History taking and physical examination
prepared by Dr Muslem Artin
5th semester
1399

2. What is history taking?
• Asking questions of patients to obtain information and aid diagnosis
• Gathering data both objective and subjective for the purpose of
generating differential diagnosis, following a specific
treatment/procedure and evaluating change in the patients condition

3. Sir William Osler 1849-1919
• # always listen to the patient, they might be telling you the diagnosis#
• Medicine is learned at the bedside and not in the classroom

4. Key principles of patient assessment
• It is estimated that 80% of diagnosis are based on history taking alone
• Ensure the patient is as comfortable as possible
• Introduce your name and status with a freindly greeting
• Explain the purpose of your interview
• Listen to what the patient says and involve the patient
• Maintain privacy and dignity
• Use a systematic approach

5. Classic history taking sequence
• Identification
• Chief Complaints(CC)
• Present illness(PI)
• Past history/Family history/Drug history/Personal history/Allergy *immumity history
• Physical examination(general survey-local examination-general examinaion)
• Review of system
• Provisional diagnosis
• Special investigation
• Clinical diagnosis
• Treatment
• Prognosis
• Follow up
• termination

6. Identification
• Date/ refrence
• Name
• Age
• Sex
• Occupation
• Religion
• Residence or address
• Hospital number

7. Chief Complaints(CC)
• Signs and symptoms which prompted the patient to seek medical
advice
• Duration of each sign and symptom
• If More than one complain ,they should be listed in the order of
occurence

8. Present illness(PI)
• Chronological order of events of symptoms and further clarification of each
symptom
*S site
*O onset
*C character
*R radiation(of pain or discomfort)
*A alleviating factors
*T timing
*E exacerbating factors
*S severity
Avoid medical terminology and

9. PI
• Open question : allow patients to express own thoughts and feeling
,e.g’’IS there anything else that you want to mention?
• Closed questions : are requests for factual information , e.g’’ when
did this pain start?
• Leading questions : are based on your own assumptions that lead the
patient to answer you want to hear

10. PI EXAMPLE
• The patient was apparently well 1 week before the admission, when the
patient fell while gardening and cut his foot with a stone ,
• by that evening the foot became swollen and patient was unable to walk .
• next day patient attended a private clinic where they gave him some oral
medicines,
• the patient doesn’t know the name of the medicine given but says that he
was told the medicine would suppress his leg pain, however there was no
improvement in his condition,
• two days prior to admission in JNMC, the swelling in the foot started to
discharge pus, there is high fever with nausea and vomiting,

11. Past History
• Listing of illness unrelated to the present illness , experienced in the
past Including childhood disease
• Serious injuries and surgery
• Mention of each disease with an approximate date ,severity duration
complication and sequel(consequences)is essential

12. Drug History:
• Anti hypertensive
• Antindabetic
• Steroid
• …

13. Family History
• Father and mother : age , health , date and cause of death
• Sibling ; list with ages ,health (if death mention of death)
• Family disease :tuberculosis ,diabetes mellitus ,hypertensive disorder
,migraine

14. Personal History
• Education :school history
• Habit :dietary ,alcohol ,tobacco ,drug
• Marital status

15. Allergy History:
• Infantile eczema
• Drug sensitivity
• Utricaria
• Asthma
Immunity History:
Pediatrics and pregnants