This document provides guidance on taking a thorough patient history. It emphasizes that history taking is a crucial first step, even with advanced medical tests. The document outlines the key components of a patient history, including: presenting complaints, history of presenting complaints, past medical history, drug allergies, treatment history, social status, and family history. Taking a complete history helps establish the patient's situation and aids in accurate diagnosis. The document provides examples of questions to ask for each component of the medical history.

2. REFERENCES
• Hutchison's Clinical Methods 25th edition
• Manual of practical medicine 4th edition by R. ALAGAPPAN

3. IMPORTANCE OF HISTORY TAKING
“History taking and clinical examination are initial but crucial steps to
achieving this understanding, even in an era in which the availability of
sophisticated investigations might suggest to a lay person that a blood
test or scan will give all the answers. In addition, even though many
diseases are now curable, the relief of symptoms is usually what the
patient expects from the medical process.”
…Hutchison's Clinical Methods 25th edition.

4. WHAT WE SHOULD KNOW…
PRESENTING COMPLAINTS
PATIENT CONDITION
HABITS OF THE PATIENT
SOCIAL AND ECONOMIC STATUS
PAST MEDICAL HISTORY
All these will help in diagnosing the patient.

5. HOW YOU GREET YOUR PATIENT
• Greet the patient by name.
• Make eye contact
• Display confidence and
professionalism.
• Explain everything they will be doing
and review the plan of care, making
sure to involve them in decision
making.
• Maintaining patient privacy is
essential.

6. COMPONENTS OF HISTORY TAKING
INTRODUCTION
PRESENTING COMPLAINT
H/O PRESENTING COMPLAINT
PAST HISTORY
H/O ALLERGIES
DRUG SENSITIVITIES
TREATMENT HISTORY
SOCIAL AND ECONOMIC STATUS
FOR FEMALE MENSTRUAL, PREGNANCY, ABORTION AND MTP HISTORY
FAMILY HISTORY

7. INTRODUCTION
• NAME
• AGE
• OCCUPATION
• RESIDENCE
• PHONE NUMBER
Example: Patient named DARSI LAKSHMI age 28 YEARS native of
THIMMAPURAM village was working as a daily labour in a near by
TEXTILE INDUSTRY.

8. PRESENTING COMPLAINT
• Allow the patient to tell his
complaints in his own words.
• Do not put leading questions to
the patient.
• The current complaints and
their duration should be noted
in a chronological order
Example: Difficulty in breathing
since today morning.
So, here difficulty in breathing is
the presenting complaint of
patient and duration is since
morning.

9. HISTORY OF PRESENTING COMPLAINT
• Onset
• Nature
• Course
• Associated symptoms
• Duration of each symptom.
• Aggrevating and relieving factors.
Example:
Patient is having dry cough i.e is cough without expectoration for the past 3
days with onset of breathlessness since today morning.

10. PAST HISTORY
• Did the patient presented with
similar complaints in the past
• If present when and how
frequently he/she is having
these episodes.
Example: Patient informs she is
having similar episode 3 months
back and relieved on medication
by a local practitioner.

11. HISTORY OF ALLERGIES
What is an allergy ?
Allergies are hypersensitive responses from the immune system to substances
that either enter or come into contact with the body.
Common presentation of these allergies
Cold
Cough
Rashes
Sneezes
Facial edema

12. • Common allergens
• Dust
• Mites
• Pollen
• Some kinds of foods
• Drugs
Example :
Here our patients explains she will get continues sneezes when she was
exposed to dust or cold environment.

13. TREATMENT HISTORY
This should include all previous medical
and surgical treatment and also any
medication that the patient may be
continuing to take to the present date.
Details of drugs taken, including anti
hypertensives, hypoglycemics, analgesics,
oral contraceptives, psychotropic drugs
and of previous surgery and radiotherapy
are particularly important.

14. DRUG SENSITIVITIES
• Some people are allergic or
sensitive to drugs that are not
harmful for most people.
• Some drugs, such as aspirin and
penicillin or related antibiotics,
may induce allergic reactions in
some children and sensitivities in
others.

15. SOCIAL AND ECONOMIC STATUS
• Enquire about the patient’s family life
style, daily habits, and diet.
• Nature of the patient’s work (hard
work or sedentary).
• Possibility of over crowding at home
(over crowding aids in the spread of
communicable diseases) and the
sanitation in and around the house.

16. • Presence of pets in the house.
• Use of alcohol, tobacco (whether
chewed or smoked) and betel
nut.
• Enquire about history of travel
abroad or other places within
the country, as it may give a
clue to the import of a disease
by the patient, endemic in the
place visited.

17. MENSTRUAL HISTORY
• The following enquiries are made:
• i. Age of menarche
• ii. Duration of each cycle
• iii. Regular or irregular cycles
• iv. Approximate volume of blood loss in
each menstrual cycle
• v. Age of attainment of menopause
• vi. Post-menopausal bleeding.

18. OBSTETRIC HISTORY
The following enquiries are made:
i. Number of times the patient
conceived.
ii. Number of times pregnancy was
carried to term.
iii. Number of abortions.
iv. Number of living children, their ages
and the age of the last child delivered.
v. The time interval between successive
pregnancies/abortions.
vi. Mode of delivery (vaginal, forceps
assisted, or caesarean).
vii. Development of oedema legs,
hypertension or seizures in the antenatal
or postnatal period.
viii. Gestational diabetes
ix. Tubectomy or Hysterectomy.

19. OCCUPATIONAL HISTORY
• Enquiry must be made on all previous and
present occupation, as it may give a clue to
the presence of an occupational disease in
the patient and also to plan the
rehabilitation
• example
i. Mesothelioma—exposure to asbestos
ii. Carcinoma of the urinary bladder -
dye industries
iii. Silicosis—occurs in mine workers.

20. • On the other hand, the presence
of a disease in an individual may
make him unfit for his occupation
by proving to be hazardous to him
as well as to others,
• Example
i. Salmonella infection or
carrier state in food handlers.
ii. Epilepsy in drivers of public
transport vehicles

21. FAMILY HISTORY
Detail of the family history
• Are there any illnesses that run in
your family?
• Basic family tree of first-degree
relatives
• Specific questions about occurrence
of problems similar to the patient’s

22. THANK YOU