History Taking 1.Name, age, sex, marital status, occupation, address (Demographics) 2. Presenting complaints 3. History of present illness 4. Systemic inquiry 5. Past history 6. Menstrual history 7. Treatment history 8. Family history 9. Personal and social history 10. Occupational history

2. History Taking
By
DPT 5th Boys
Presented to:
Dr. Anam Maqbool

3. Why we Need?
Before Going towards the main topic:
What is History Taking?
To know about the patients illness as he knows

4. Each day in the clinic, physical and occupational therapists, physical therapist assistants
(PTAs), certified occupational therapy assistants (COTAs), and other health care
professionals Document patient care.
Patient/Client Management
Note
SOAP Note
• S stands for Subjective.
• O stands for Objective.
• A stands for Assessment.
• P stands for Plan.
• History
• Systems Review
• Tests and Measures
• Evaluation
• Diagnosis
• Prognosis
• Plan of Care

5. The Purposes of Documentation
6. Patient care notes record what the therapist does to
manage the individual patient’s case.
2. Good documentation is a method of communicating with
all other health care professionals, including physicians,
other therapists, and therapist assistants.
3. Patient care notes written by the therapist or assistant
may contribute significantly to discharge planning.
4. By thinking in a structured manner with the use of
evidence, the therapist can better make decisions regarding
patient care.
5. Documentation of patient care can be used for quality
assurance and improvement purposes.
7 .Patient care notes can be used in outcomes research.
1. Good documentation can help to educate others,
including other health care professionals, third-party
payors, and our patients, about the services that physical
therapy can provide.

6. • This is an interview with the patient aimed to understanding
the nature of his illness.
• It can be defined as to know about the patients illness as he
knows.
History Taking
The process of history taking cannot be restricted to a predefined pattern and
has to be modified according to the patient’s symptoms, attitude, age and level
of literacy.

7. Your approach to the patient should
be sympathetic, gentle, friendly and
confident but not frivolous, sarcastic
or belittling.
Introduce yourself to the patient
first.
Try to communicate in the language
which the patient fully
understand.
Be courteous; in the hospital,
don't interrupt patient's personal
activities like eating etc. You should,
either wait for the patient to finish
or come some other time.
Allow the patient to give his own
account of current illness and then
ask questions about aspects that
remain deficient.
If interruption is necessary, it should
be timed and planned depending
upon patient's personality.
Try to avoid asking leading
questions.
Encourage the patient to give details
of his symptoms and discourage
the use of pseudo medical terms
like 'rheumatism' 'acidity' etc. Don't
accept a diagnosis except if it has
been made by somebody competent
and has been based `on definite
external tests as required; otherwise
ask details of the illness as it
occurred.
Avoid writing when the patient is
talking. This will give an impression
as if you are not attentive.

8. Write down the history under the following headings:
1. Name, age, sex, marital status, occupation, address (Demographics)
2. Presenting complaints
3. History of present illness
4. Systemic inquiry
5. Past history
6. Menstrual history
7. Treatment history
8. Family history
9. Personal and social history
10. Occupational history

9. Demographics
Name
This is the identity of the patient. Record
the father's or husbands name as well in
order to differentiate between individuals
with the same name.
Age
Some patients are not sure about their
age. An approximate age can be assessed
by the look of the patient. Information
like age at the time of marriage and age
of eldest child also can help.
Some diseases are more common in
certain age groups, eg, communicable
diseases like polio, chicken pox, measles
etc. are common in childhood while
malignancies, ischemic heart disease,
strokes are more common in older age
group.
Sex
Apart from identification value and
specific diseases of genital organs, certain
disorders are more common in one
particular sex, e.g., ischemic heart disease
is more common in males while systemic
lupus erythematosus and primary biliary
cirrhosis are more common in females.
Occupation
It not only gives clue about patient's socio-
economic and educational status but also
tells about possible risk to his health. It is
further discussed under occupational
history.
Address
Complete postal address is vital for future
communication. In addition, some
problems like iodine deficiency, parasitic
infestations are more prevalent in certain
regions, knowledge of patient's address
may help in the diagnosis.

10. These are the symptoms which made the patient to come to the
doctor. Record them in chronological order, i.e, write the symptom
which developed first at the top followed by other complaints in
sequence of occurrence. Enter duration of each complaint in front of it.
If a symptom has been occurring again and again, and is present this
time as well, include this information in presenting complaint.
If patient had certain symptoms before presenting complaints but this
time he has not come for those symptoms, record them under the past
histoy.
Presenting Complaints

11. Describe the presenting complaints in detail one by one; in the sequence
they developed. Relevant questions to be asked about various symptoms
are learnt only with experience and increasing knowledge of Medicine. A
list of such questions about important symptoms is Given Here.
If symptoms have been occurring in bouts, describe the latest episode in
detail and then record duration, frequency and progress of these
episodes from the beginning. Record the history in patient's words and
don't substitute medical terms for patient's description, e.g., paroxysmal
nocturnal dyspnea for breathlessness during the night and angina for
chest pain on exertion.
History of Present Illness

12. The patient generally tends to tell only those symptoms which
he thinks are important and need immediate attention of the
doctor. Either he ignores other symptoms, considering them
unimportant/unrelated to present illness or he might even
forget some of the less severe symptoms.
In order to make sure that no aspect of the patient's illness is
missed, it is recommended that you should ask about all the
cardinal symptoms of each system as a routine under the
heading of systemic inquiry.
Systemic Inquiry

13. General
Appetite, weight gain or weight
loss, sleep, energy.
Cardiovascular System
Breathlessness, palpitation,
chest pain, edema feet.
Respiratory System
Cough, sputum, hemoptysis,
breathlessness, wheezing,
chest pain.
Alimentary System
Nausea, vomiting, abdominal
pain, heartburn, dysphasia,
diarrhea, constipation,
hematemesis, melena,
jaundice.
Urinary System
Pain in the flanks, dysuria,
hematuria, frequency of
micturition, polyuria, oliguria,
nocturia, passage of gravel in
the urine, nausea, vomiting.
Nervous System
Weakness, numbness, tingling,
headache, vomiting, giddiness,
blackouts, fits, visual loss,
diplopia.
Skin
Rash, itch, colored spots.
Locomotor System
Joint pain, stiffness, swelling,
restriction of movements
Endocrine
Polyuria polyphagia,
polydypsia, heat or cold
intolerance, weight gain or loss,
sweating, palpitation.
Systemic Inquiry

14. In certain situations patient himself cannot give the details of
history. Seek the information from another person, particularly an
eye witness.
These situations include:
• Childhood.
• Senility or mental retardation.
• Unconscious/aphasic patient.
• Convulsions with loss consciousness.
Information from Another Person

15. • Nature of delivery (spontaneous, assisted or Cesarean section;
at home or in hospital). It is more relevant in children.
• Congenital anomalies. Communicable diseases in childhood.
• Any significant illness (ask description of illness if diagnosis is
not known).
• History of admission to hospital, accident or operation; ask
more details if the answer is yes.
• Any chronic illness like hypertension, diabetes mellitus, ischemic
heart disease, arthritis, tuberculosis. if someone has one of
these illnesses, ask how and when it was diagnosed, what
treatment he has been taking and how effectively it has been
controlled.
• Residence or travel abroad. It is becoming more relevant due to
frequent travel and emergence of diseases like AIDS.
Past History

16. Note down the following:
• Age of menarche (onset of menstruation).
• Duration of each period. Length of cycle (from the
1st day of one period to the 1st day of next period).
• Regularity of cycle.
• Any pain associated with periods: site, duration,
relationship to the onset of periods.
• Any intermenstrual or postcoital bleeding.
• Menopause; age, postmenopausal bleeding or
discharge.
Menstrual History

17. • Patients usually don't remember names of drugs. Ask about any left over
drugs, labels or prescription.
• Note down names of drugs, dosage and duration of therapy.
• Also ask about effect of these drugs on patient's illness.
• If patient has a prescription, find out whether he is taking all the drugs in the
prescribed doses.
• If patient was not taking drugs regularly, find out the cause of non-
compliance.
• Knowledge of drugs taken might give a clue to the nature of patient's past or
even existing disease.
• Side effects of drugs are sometimes responsible for patient's symptoms.
• Some patients are sensitive to drugs like sulfonamides, penicillin etc. and this
information helps to avoid any catastrophes
• It helps to avoid any possible drug interaction with newly prescribed drugs,
e.g., anticoagulant may interact with oral contraceptives which patient is
already taking.
Treatment History

18. • Inquire about health of parents, siblings (brother and sister)
and children, and ask questions about individual member.
• Find out whether any one of them is suffering from a similar
illness or a chronic illness like hypertension, diabetes mellitus,
ischemic heart disease, asthma, arthritis or tuberculosis?
• If any one of them is dead, ask about possible cause of death.
• If there is suspicion of inherited disorder, ask about health of
uncles and aunts as well.
Family History

19. • Patient's economic status. It is important to decide how much patient
will be able to afford the cost of investigations and treatment.
• Nature of family relations.
• Any habit or addiction, now or in the past like smoking, drug
dependence, alcohol intake.
• Any special worries, sleep disturbance.
• Dietary details if there is doubt of nutritional abnormality.
• Home surroundings.
Personal and Social History

20. Seek the following information:
• Exact nature of the present job.
• Details of jobs in the past.
• Any possibility of exposure to chemicals or radiations? If yes,
what is their nature and quantity?
• How much physical Activity is involved?
Occupational History