History taking is a critical process for physicians to obtain useful information from patients to formulate diagnoses and provide medical care. It involves asking specific questions to gain information about a patient's chief complaint, history of present illness, past medical history, family history, and systems review. An accurate history obtained through good communication skills is important, as the diagnosis can often be determined from the history alone in about 70% of cases. The history should be taken in a structured manner, with open-ended questions to allow the patient to provide their full account before asking focused questions.
History taking involves gaining information from patients through directed questioning to aid medical diagnosis and care. It is critical for determining the cause of a patient's illness, as diagnosis is often based on clinical history alone. An accurate history is obtained by addressing key components in order: chief complaint, history of present illness, past medical history, family history, and personal history. Open-ended questions allow patients to provide their own perspective, while closed questions clarify specific details chronologically. History taking is an essential medical skill developed through focused practice and attention to patient communication.
This document provides guidance on performing a neurological history and physical examination. It emphasizes that history taking is one of the most important skills, as it can help identify and localize neurological pathology. The key aspects of history taking outlined are introducing oneself to the patient, obtaining consent, listening to the patient, and documenting the assessment clearly. The document then describes the components of a complete history, including chief complaint, history of present illness, past medical history, medications, and systems review. It also provides details on performing a neurological examination and using tools like the Mini-Mental State Examination to evaluate cognition.
The document provides guidance on taking an effective ophthalmic patient history. It emphasizes the importance of obtaining an accurate history, which can often provide a diagnosis. The history should include introducing oneself, chief complaint, history of present illness, past medical history, drug history, family history, and social history. Key details and tips are provided on questioning patients and documenting each component of the history.
The document provides guidance on taking a patient's medical history. It discusses the importance of obtaining an accurate history and outlines the general approach and structure for conducting a history, including introducing oneself, ensuring confidentiality, listening to the patient, and asking open-ended questions. It then covers how to record specific components of the history, such as the chief complaint, history of present illness, past medical history, drug history, family history, and social history.
This document provides guidance on performing a thorough patient history. It outlines the key components of a patient history, including chief complaint, history of present illness, past medical history, drug history, family history, and social history. The importance of obtaining an accurate history is emphasized as it allows the healthcare provider to determine the etiology of the patient's problem. Guidelines are provided on how to conduct each part of the history respectfully and obtain relevant information through active listening and open-ended questioning.
This document provides guidance on taking a thorough medical history. It outlines the key components of a medical history, including identifying data, chief complaint, present illness, past medical history, family history, social history, and review of systems. The present illness section should provide a chronological account of the patient's symptoms and issues that prompted them to seek care. Gathering detailed information about symptoms, such as location, quality, timing and exacerbating/relieving factors is important for diagnosis. A comprehensive history helps health workers understand the patient's perspective and identify pertinent medical factors.
History taking is a critical process for physicians to obtain useful information from patients to formulate diagnoses and provide medical care. It involves asking specific questions to gain information about a patient's chief complaint, history of present illness, past medical history, family history, and systems review. An accurate history obtained through good communication skills is important, as the diagnosis can often be determined from the history alone in about 70% of cases. The history should be taken in a structured manner, with open-ended questions to allow the patient to provide their full account before asking focused questions.
History taking involves gaining information from patients through directed questioning to aid medical diagnosis and care. It is critical for determining the cause of a patient's illness, as diagnosis is often based on clinical history alone. An accurate history is obtained by addressing key components in order: chief complaint, history of present illness, past medical history, family history, and personal history. Open-ended questions allow patients to provide their own perspective, while closed questions clarify specific details chronologically. History taking is an essential medical skill developed through focused practice and attention to patient communication.
This document provides guidance on performing a neurological history and physical examination. It emphasizes that history taking is one of the most important skills, as it can help identify and localize neurological pathology. The key aspects of history taking outlined are introducing oneself to the patient, obtaining consent, listening to the patient, and documenting the assessment clearly. The document then describes the components of a complete history, including chief complaint, history of present illness, past medical history, medications, and systems review. It also provides details on performing a neurological examination and using tools like the Mini-Mental State Examination to evaluate cognition.
The document provides guidance on taking an effective ophthalmic patient history. It emphasizes the importance of obtaining an accurate history, which can often provide a diagnosis. The history should include introducing oneself, chief complaint, history of present illness, past medical history, drug history, family history, and social history. Key details and tips are provided on questioning patients and documenting each component of the history.
The document provides guidance on taking a patient's medical history. It discusses the importance of obtaining an accurate history and outlines the general approach and structure for conducting a history, including introducing oneself, ensuring confidentiality, listening to the patient, and asking open-ended questions. It then covers how to record specific components of the history, such as the chief complaint, history of present illness, past medical history, drug history, family history, and social history.
This document provides guidance on performing a thorough patient history. It outlines the key components of a patient history, including chief complaint, history of present illness, past medical history, drug history, family history, and social history. The importance of obtaining an accurate history is emphasized as it allows the healthcare provider to determine the etiology of the patient's problem. Guidelines are provided on how to conduct each part of the history respectfully and obtain relevant information through active listening and open-ended questioning.
This document provides guidance on taking a thorough medical history. It outlines the key components of a medical history, including identifying data, chief complaint, present illness, past medical history, family history, social history, and review of systems. The present illness section should provide a chronological account of the patient's symptoms and issues that prompted them to seek care. Gathering detailed information about symptoms, such as location, quality, timing and exacerbating/relieving factors is important for diagnosis. A comprehensive history helps health workers understand the patient's perspective and identify pertinent medical factors.
History taking- oral pathology- Sreng at UHSSreng Pouv
History taking is very important for all doctor and dentist. Therefore, all doctor and dentist must spend 5-10mins for taking history from patients because it can make doctor's or dentist's treatment efficiency and potentially. In history-taking, there are 5 vital elements. They are :
- Date collection and chief complaint.
- Present History
- Past History
- Personal History
- Family History.
In those slides, also include the behaviour of doctor or dentist.
During interview, Dentist should be :
introduce yourself and asking some normal questions => patient feel comfortable for moving forward.
always listen carefully.
keep your appearance neat and clean => gain trust.
show courteous, respectful and confidential
always be friendly and interest in patients’ problems.
keep eye contact.
3 history taking & physical examinationawadfadlalla1
This document provides information on nursing history taking and physical examination. It discusses the importance of obtaining an accurate patient history, which is critical for diagnosis. The key components of history taking are identified as demographic data, chief complaint, history of present illness, past medical history, family history, drug history, review of systems, and physical examination. The principles and techniques of physical examination are outlined, including inspection, palpation, percussion, and auscultation. A head-to-toe assessment approach is recommended to perform a thorough physical exam.
The document provides guidance on how to conduct a thorough patient history, including how to structure the history taking session and how to approach each component of the history. It discusses taking the chief complaint, history of present illness, past medical history, drug history, family history, and social history. For each component, it provides tips on what information to obtain and how to record it in the patient's own words. It also describes doing a review of all body systems to check for any associated symptoms.
Here are the key points to ascertain the genuine nature of a complaint:
- Verify details like duration, frequency, severity, associated symptoms
- Ask others who interact with the patient like family members
- Look for objective signs that correlate with the complaint
- Record and monitor vital parameters over time
- Consider potential confounding factors like efforts for secondary gain
History taking involves systematically gathering subjective and objective patient information through questioning to aid in diagnosis. It is estimated that 80% of diagnoses are based on history taking alone. The classic sequence includes gathering identifying information, chief complaints, present illness details using the SOCRATES mnemonic, and reviewing past, family, drug, and systems histories. The present illness details should be obtained in chronological order using open-ended questions to allow the patient to freely provide their experience without assumptions. History taking is an important clinical skill that provides crucial context to inform physical examination and assessment.
The document discusses effective techniques for taking a patient's medical history. It recommends starting with standard questions about the chief complaint, including location, quality, duration, aggravating/relieving factors, and effect on function. The history aims to identify relevant organ systems, clarify pathological processes, and characterize the social context of the patient's illness. Key elements include patient identification, profile, and chief complaints. Effective techniques include adopting a conversational style, listening without interrupting, clarifying terms, summarizing, and utilizing open-ended questions initially.
THESE SLIDES ARE PREPAREED TO UNDERSTAND about HEALTH ASSESSMENT- HISTORY TAKING IN EASY WAY Important links- NOTES- https://mynursingstudents.blogspot.com/ youtube channel https://www.youtube.com/c/MYSTUDENTSU... CHANEL PLAYLIST- ANATOMY AND PHYSIOLOGY-https://www.youtube.com/playlist?list=PL93S13oM2gAPM3VTGVUXIeswKJ3XGaD2p COMMUNITY HEALTH NURSING- https://www.youtube.com/playlist?list=PL93S13oM2gAPyslPNdIJoVjiXEDTVEDzs CHILD HEALTH NURSING- https://www.youtube.com/playlist?list=PL93S13oM2gANcslmv0DXg6BWmWN359Gvg FIRST AID- https://www.youtube.com/playlist?list=PL93S13oM2gAMvGqeqH2ZTklzFAZhOrvgP HCM- https://www.youtube.com/playlist?list=PL93S13oM2gAM7mZ1vZhQBHWbdLnLb-cH9 FUNDAMENTALS OF NURSING- https://www.youtube.com/playlist?list=PL93S13oM2gAPFxu78NDLpGPaxEmK1fTao COMMUNICABLE DISEASES- https://www.youtube.com/playlist?list=PL93S13oM2gAOWo4IwNjLU_LCuhRN0ZLeb ENVIRONMENTAL HEALTH- https://www.youtube.com/playlist?list=PL93S13oM2gAPkI6LvfS8Zu1nm6mZi9FK6 MSN- https://www.youtube.com/playlist?list=PL93S13oM2gAOdyoHnDLAoR_o8M6ccqYBm HINDI ONLY- https://www.youtube.com/playlist?list=PL93S13oM2gAN4L-FJ3s_IEXgZCijGUA1A ENGLISH ONLY- https://www.youtube.com/playlist?list=PL93S13oM2gAMYv2a1hFcq4W1nBjTnRkHP facebook profile- https://www.facebook.com/suresh.kr.lrhs/ FACEBOOK PAGE- https://www.facebook.com/My-Student-S... facebook group NURSING NOTES- https://www.facebook.com/groups/24139... FOR MAKING EASY NOTES YOU CAN ALSO VISIT MY BLOG – BLOGGER- https://mynursingstudents.blogspot.com/ Instagram- https://www.instagram.com/mystudentsu... Twitter- https://twitter.com/student_system?s=08 #PEM,#historytaking,#communicablediseases,#ASSESSMENT, #APPEARENCE,#PULSE,#GRIMACE,#REFLEX,#RESPIRATION,#RESUSCITATION,#NEWBORN,#BABY,#VIRGINIA, #CHILD, #OXYGEN,#CYANOSIS,#OPTICNERVE, #SARACHNA,#MYSTUDENTSUPPORTSYSTEM, #rashes,#nursingclasses, #communityhealthnursing,#ANM, #GNM, #BSCNURING,#NURSINGSTUDENTS, #WHO,#NURSINGINSTITUTION,#COLLEGEOFNURSING,#nursingofficer,#COMMUNITYHEALTHOFFICE,#HEALTHPROBLEMS
tHESE SLIDES ARE PREPAREED TO UNDERSTAND about HEALTH ASSESSMENT IN EASY WAY Important links- NOTES- https://mynursingstudents.blogspot.com/ youtube channel https://www.youtube.com/c/MYSTUDENTSU... CHANEL PLAYLIST- ANATOMY AND PHYSIOLOGY-https://www.youtube.com/playlist?list=PL93S13oM2gAPM3VTGVUXIeswKJ3XGaD2p COMMUNITY HEALTH NURSING- https://www.youtube.com/playlist?list=PL93S13oM2gAPyslPNdIJoVjiXEDTVEDzs CHILD HEALTH NURSING- https://www.youtube.com/playlist?list=PL93S13oM2gANcslmv0DXg6BWmWN359Gvg FIRST AID- https://www.youtube.com/playlist?list=PL93S13oM2gAMvGqeqH2ZTklzFAZhOrvgP HCM- https://www.youtube.com/playlist?list=PL93S13oM2gAM7mZ1vZhQBHWbdLnLb-cH9 FUNDAMENTALS OF NURSING- https://www.youtube.com/playlist?list=PL93S13oM2gAPFxu78NDLpGPaxEmK1fTao COMMUNICABLE DISEASES- https://www.youtube.com/playlist?list=PL93S13oM2gAOWo4IwNjLU_LCuhRN0ZLeb ENVIRONMENTAL HEALTH- https://www.youtube.com/playlist?list=PL93S13oM2gAPkI6LvfS8Zu1nm6mZi9FK6 MSN- https://www.youtube.com/playlist?list=PL93S13oM2gAOdyoHnDLAoR_o8M6ccqYBm HINDI ONLY- https://www.youtube.com/playlist?list=PL93S13oM2gAN4L-FJ3s_IEXgZCijGUA1A ENGLISH ONLY- https://www.youtube.com/playlist?list=PL93S13oM2gAMYv2a1hFcq4W1nBjTnRkHP facebook profile- https://www.facebook.com/suresh.kr.lrhs/ FACEBOOK PAGE- https://www.facebook.com/My-Student-S... facebook group NURSING NOTES- https://www.facebook.com/groups/24139... FOR MAKING EASY NOTES YOU CAN ALSO VISIT MY BLOG – BLOGGER- https://mynursingstudents.blogspot.com/ Instagram- https://www.instagram.com/mystudentsu... Twitter- https://twitter.com/student_system?s=08 #PEM, #ASHA,#DIPHTHERIA,#ICDS,#nurses,#ASSESSMENT, #APPEARENCE,#PULSE,#GRIMACE,#REFLEX,#RESPIRATION,#RESUSCITATION,#NEWBORN,#BABY,#VIRGINIA, #CHILD, #OXYGEN,#CYANOSIS,#OPTICNERVE, #SARACHNA,#MYSTUDENTSUPPORTSYSTEM, #rashes,#nursingclasses, #communityhealthnursing,#ANM, #GNM, #BSCNURING,#NURSINGSTUDENTS, #WHO,#NURSINGINSTITUTION,#COLLEGEOFNURSING,#nursingofficer,#COMMUNITYHEALTHOFFICE
History Taking (Checklist) - Elsevier HealthUpdesh Yadav
The document provides guidance on taking a patient's medical history. It discusses the importance of history taking in diagnosis and building trust with patients. The goals of history taking are to identify relevant medical issues, clarify pathological processes, and understand the social context of the patient's illness. It then outlines various techniques for an effective history, including allowing the patient to provide their account without interruption, asking open-ended questions, avoiding leading questions, and summarizing the story for confirmation. The document concludes by presenting a sample sequence for history taking.
The document discusses the importance and process of history taking in medicine. It outlines the key aims as identifying the organ system responsible for symptoms, clarifying the pathological processes, and characterizing the social context of illness. It then describes the techniques of history taking, including allowing the patient to provide their account without interruption, summarizing the story to check accuracy, and using a typical sequence of introduction, presenting complaint, history of current illness, past medical history, drugs/allergies, family history, and social/personal history. The document emphasizes listening to the patient, establishing rapport, avoiding leading questions, and obtaining detailed symptom descriptions.
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
The document discusses the importance of taking a thorough medical history. It outlines that a history is the first step in diagnosis and is often the least expensive way to determine the correct diagnosis. It also emphasizes that history taking requires establishing rapport with the patient and developing one's own systematic technique through practice and experience. A table provides a suggested sequence for obtaining a patient's history.
1) History taking is an essential nursing skill that provides information to make an accurate diagnosis. It involves obtaining a patient narrative through structured questioning.
2) Key principles of history taking include actively listening to the patient, maintaining privacy and confidentiality, using a systematic approach, and ensuring patient comfort.
3) The standard format includes collecting biographical data, chief complaint, history of present complaint, past medical history, medication history, family history, and reviewing all body systems. Summarizing each section ensures clear understanding before moving forward.
Presentation on various parameters in patient profile form.....manik chhabra.
The document provides information on various parameters that should be included in a patient's medical history and physical examination. It discusses the importance of gathering information on the patient's present illness, past medical history, family history, social history, allergies, and performing a physical examination. A provisional diagnosis may be made based on the information collected, but more information is needed to determine the actual diagnosis. The examination involves observing the patient and evaluating various body systems such as cardiovascular, respiratory, and neurological. Specific things to note include edema, pallor, koilonychia, cyanosis, clubbing, and jaundice.
This document outlines the process and components of taking a patient's medical history. It discusses introducing oneself to the patient, obtaining their chief complaint, history of present illness, past medical history, family history, drug history, and social history. It emphasizes listening to the patient, asking open-ended questions, avoiding medical terminology, and recording all information in the patient's own words. The goal is to accurately determine the etiology of the patient's illness based on their history.
The document provides guidance on history taking for pediatricians. It outlines the key attributes required of pediatricians including knowledge, skills, patience and compassion. It describes how to build rapport with children and parents through friendly behavior, making eye contact, and asking open-ended questions. The objectives and process of history taking are explained, with tips on listening actively and avoiding judgment. The document then details the various aspects of medical history to cover, such as presenting complaints, review of systems, past medical history, family history, and immunization status.
History Taking for Health Professionals, Nurses Pooja Koirala
This document provides guidelines for taking a patient's medical history. It outlines the key components of a history, including biographical information, chief complaints, history of present illness, past medical history, family history, and review of systems. The guidelines describe how to systematically collect information on symptoms, onset, severity, treatments received, and associated factors. Proper techniques for history taking are also covered, such as establishing rapport, active listening, maintaining privacy, and using a structured format to document the patient's history in a clear and organized manner.
This document provides an overview of the health assessment process, including the purpose, components, and guidelines for taking a patient's health history. The main points are:
- The purpose of a health assessment is to collect physical, mental, and social data about a client to identify problems, make clinical decisions, and evaluate outcomes of care.
- Taking a health history is a key part of the assessment process and involves systematically gathering both subjective data from the client and objective data observed by the nurse.
- There are several components that should be covered during a health history, including biographical data, chief complaints, history of present illness, past medical history, and family, social, and occupational information.
-
The document provides information on how to take a patient's medical history. It discusses the components of a medical history including:
1. Chief complaint - the patient's reason for visiting stated in their own words.
2. History of present illness (HPI) - details of the current illness including duration, severity, treatments tried, and associated symptoms.
3. Past medical history (PHM) - includes past illnesses, surgeries, medications, allergies, hospitalizations, and health maintenance.
4. Family history - focuses on hereditary illnesses in first and second degree relatives.
The document emphasizes using open-ended questions and following up with questions about duration, severity and other details to fully understand
Strategies for Effective Upskilling is a presentation by Chinwendu Peace in a Your Skill Boost Masterclass organisation by the Excellence Foundation for South Sudan on 08th and 09th June 2024 from 1 PM to 3 PM on each day.
A review of the growth of the Israel Genealogy Research Association Database Collection for the last 12 months. Our collection is now passed the 3 million mark and still growing. See which archives have contributed the most. See the different types of records we have, and which years have had records added. You can also see what we have for the future.
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History taking- oral pathology- Sreng at UHSSreng Pouv
History taking is very important for all doctor and dentist. Therefore, all doctor and dentist must spend 5-10mins for taking history from patients because it can make doctor's or dentist's treatment efficiency and potentially. In history-taking, there are 5 vital elements. They are :
- Date collection and chief complaint.
- Present History
- Past History
- Personal History
- Family History.
In those slides, also include the behaviour of doctor or dentist.
During interview, Dentist should be :
introduce yourself and asking some normal questions => patient feel comfortable for moving forward.
always listen carefully.
keep your appearance neat and clean => gain trust.
show courteous, respectful and confidential
always be friendly and interest in patients’ problems.
keep eye contact.
3 history taking & physical examinationawadfadlalla1
This document provides information on nursing history taking and physical examination. It discusses the importance of obtaining an accurate patient history, which is critical for diagnosis. The key components of history taking are identified as demographic data, chief complaint, history of present illness, past medical history, family history, drug history, review of systems, and physical examination. The principles and techniques of physical examination are outlined, including inspection, palpation, percussion, and auscultation. A head-to-toe assessment approach is recommended to perform a thorough physical exam.
The document provides guidance on how to conduct a thorough patient history, including how to structure the history taking session and how to approach each component of the history. It discusses taking the chief complaint, history of present illness, past medical history, drug history, family history, and social history. For each component, it provides tips on what information to obtain and how to record it in the patient's own words. It also describes doing a review of all body systems to check for any associated symptoms.
Here are the key points to ascertain the genuine nature of a complaint:
- Verify details like duration, frequency, severity, associated symptoms
- Ask others who interact with the patient like family members
- Look for objective signs that correlate with the complaint
- Record and monitor vital parameters over time
- Consider potential confounding factors like efforts for secondary gain
History taking involves systematically gathering subjective and objective patient information through questioning to aid in diagnosis. It is estimated that 80% of diagnoses are based on history taking alone. The classic sequence includes gathering identifying information, chief complaints, present illness details using the SOCRATES mnemonic, and reviewing past, family, drug, and systems histories. The present illness details should be obtained in chronological order using open-ended questions to allow the patient to freely provide their experience without assumptions. History taking is an important clinical skill that provides crucial context to inform physical examination and assessment.
The document discusses effective techniques for taking a patient's medical history. It recommends starting with standard questions about the chief complaint, including location, quality, duration, aggravating/relieving factors, and effect on function. The history aims to identify relevant organ systems, clarify pathological processes, and characterize the social context of the patient's illness. Key elements include patient identification, profile, and chief complaints. Effective techniques include adopting a conversational style, listening without interrupting, clarifying terms, summarizing, and utilizing open-ended questions initially.
THESE SLIDES ARE PREPAREED TO UNDERSTAND about HEALTH ASSESSMENT- HISTORY TAKING IN EASY WAY Important links- NOTES- https://mynursingstudents.blogspot.com/ youtube channel https://www.youtube.com/c/MYSTUDENTSU... CHANEL PLAYLIST- ANATOMY AND PHYSIOLOGY-https://www.youtube.com/playlist?list=PL93S13oM2gAPM3VTGVUXIeswKJ3XGaD2p COMMUNITY HEALTH NURSING- https://www.youtube.com/playlist?list=PL93S13oM2gAPyslPNdIJoVjiXEDTVEDzs CHILD HEALTH NURSING- https://www.youtube.com/playlist?list=PL93S13oM2gANcslmv0DXg6BWmWN359Gvg FIRST AID- https://www.youtube.com/playlist?list=PL93S13oM2gAMvGqeqH2ZTklzFAZhOrvgP HCM- https://www.youtube.com/playlist?list=PL93S13oM2gAM7mZ1vZhQBHWbdLnLb-cH9 FUNDAMENTALS OF NURSING- https://www.youtube.com/playlist?list=PL93S13oM2gAPFxu78NDLpGPaxEmK1fTao COMMUNICABLE DISEASES- https://www.youtube.com/playlist?list=PL93S13oM2gAOWo4IwNjLU_LCuhRN0ZLeb ENVIRONMENTAL HEALTH- https://www.youtube.com/playlist?list=PL93S13oM2gAPkI6LvfS8Zu1nm6mZi9FK6 MSN- https://www.youtube.com/playlist?list=PL93S13oM2gAOdyoHnDLAoR_o8M6ccqYBm HINDI ONLY- https://www.youtube.com/playlist?list=PL93S13oM2gAN4L-FJ3s_IEXgZCijGUA1A ENGLISH ONLY- https://www.youtube.com/playlist?list=PL93S13oM2gAMYv2a1hFcq4W1nBjTnRkHP facebook profile- https://www.facebook.com/suresh.kr.lrhs/ FACEBOOK PAGE- https://www.facebook.com/My-Student-S... facebook group NURSING NOTES- https://www.facebook.com/groups/24139... FOR MAKING EASY NOTES YOU CAN ALSO VISIT MY BLOG – BLOGGER- https://mynursingstudents.blogspot.com/ Instagram- https://www.instagram.com/mystudentsu... Twitter- https://twitter.com/student_system?s=08 #PEM,#historytaking,#communicablediseases,#ASSESSMENT, #APPEARENCE,#PULSE,#GRIMACE,#REFLEX,#RESPIRATION,#RESUSCITATION,#NEWBORN,#BABY,#VIRGINIA, #CHILD, #OXYGEN,#CYANOSIS,#OPTICNERVE, #SARACHNA,#MYSTUDENTSUPPORTSYSTEM, #rashes,#nursingclasses, #communityhealthnursing,#ANM, #GNM, #BSCNURING,#NURSINGSTUDENTS, #WHO,#NURSINGINSTITUTION,#COLLEGEOFNURSING,#nursingofficer,#COMMUNITYHEALTHOFFICE,#HEALTHPROBLEMS
tHESE SLIDES ARE PREPAREED TO UNDERSTAND about HEALTH ASSESSMENT IN EASY WAY Important links- NOTES- https://mynursingstudents.blogspot.com/ youtube channel https://www.youtube.com/c/MYSTUDENTSU... CHANEL PLAYLIST- ANATOMY AND PHYSIOLOGY-https://www.youtube.com/playlist?list=PL93S13oM2gAPM3VTGVUXIeswKJ3XGaD2p COMMUNITY HEALTH NURSING- https://www.youtube.com/playlist?list=PL93S13oM2gAPyslPNdIJoVjiXEDTVEDzs CHILD HEALTH NURSING- https://www.youtube.com/playlist?list=PL93S13oM2gANcslmv0DXg6BWmWN359Gvg FIRST AID- https://www.youtube.com/playlist?list=PL93S13oM2gAMvGqeqH2ZTklzFAZhOrvgP HCM- https://www.youtube.com/playlist?list=PL93S13oM2gAM7mZ1vZhQBHWbdLnLb-cH9 FUNDAMENTALS OF NURSING- https://www.youtube.com/playlist?list=PL93S13oM2gAPFxu78NDLpGPaxEmK1fTao COMMUNICABLE DISEASES- https://www.youtube.com/playlist?list=PL93S13oM2gAOWo4IwNjLU_LCuhRN0ZLeb ENVIRONMENTAL HEALTH- https://www.youtube.com/playlist?list=PL93S13oM2gAPkI6LvfS8Zu1nm6mZi9FK6 MSN- https://www.youtube.com/playlist?list=PL93S13oM2gAOdyoHnDLAoR_o8M6ccqYBm HINDI ONLY- https://www.youtube.com/playlist?list=PL93S13oM2gAN4L-FJ3s_IEXgZCijGUA1A ENGLISH ONLY- https://www.youtube.com/playlist?list=PL93S13oM2gAMYv2a1hFcq4W1nBjTnRkHP facebook profile- https://www.facebook.com/suresh.kr.lrhs/ FACEBOOK PAGE- https://www.facebook.com/My-Student-S... facebook group NURSING NOTES- https://www.facebook.com/groups/24139... FOR MAKING EASY NOTES YOU CAN ALSO VISIT MY BLOG – BLOGGER- https://mynursingstudents.blogspot.com/ Instagram- https://www.instagram.com/mystudentsu... Twitter- https://twitter.com/student_system?s=08 #PEM, #ASHA,#DIPHTHERIA,#ICDS,#nurses,#ASSESSMENT, #APPEARENCE,#PULSE,#GRIMACE,#REFLEX,#RESPIRATION,#RESUSCITATION,#NEWBORN,#BABY,#VIRGINIA, #CHILD, #OXYGEN,#CYANOSIS,#OPTICNERVE, #SARACHNA,#MYSTUDENTSUPPORTSYSTEM, #rashes,#nursingclasses, #communityhealthnursing,#ANM, #GNM, #BSCNURING,#NURSINGSTUDENTS, #WHO,#NURSINGINSTITUTION,#COLLEGEOFNURSING,#nursingofficer,#COMMUNITYHEALTHOFFICE
History Taking (Checklist) - Elsevier HealthUpdesh Yadav
The document provides guidance on taking a patient's medical history. It discusses the importance of history taking in diagnosis and building trust with patients. The goals of history taking are to identify relevant medical issues, clarify pathological processes, and understand the social context of the patient's illness. It then outlines various techniques for an effective history, including allowing the patient to provide their account without interruption, asking open-ended questions, avoiding leading questions, and summarizing the story for confirmation. The document concludes by presenting a sample sequence for history taking.
The document discusses the importance and process of history taking in medicine. It outlines the key aims as identifying the organ system responsible for symptoms, clarifying the pathological processes, and characterizing the social context of illness. It then describes the techniques of history taking, including allowing the patient to provide their account without interruption, summarizing the story to check accuracy, and using a typical sequence of introduction, presenting complaint, history of current illness, past medical history, drugs/allergies, family history, and social/personal history. The document emphasizes listening to the patient, establishing rapport, avoiding leading questions, and obtaining detailed symptom descriptions.
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
The document discusses the importance of taking a thorough medical history. It outlines that a history is the first step in diagnosis and is often the least expensive way to determine the correct diagnosis. It also emphasizes that history taking requires establishing rapport with the patient and developing one's own systematic technique through practice and experience. A table provides a suggested sequence for obtaining a patient's history.
1) History taking is an essential nursing skill that provides information to make an accurate diagnosis. It involves obtaining a patient narrative through structured questioning.
2) Key principles of history taking include actively listening to the patient, maintaining privacy and confidentiality, using a systematic approach, and ensuring patient comfort.
3) The standard format includes collecting biographical data, chief complaint, history of present complaint, past medical history, medication history, family history, and reviewing all body systems. Summarizing each section ensures clear understanding before moving forward.
Presentation on various parameters in patient profile form.....manik chhabra.
The document provides information on various parameters that should be included in a patient's medical history and physical examination. It discusses the importance of gathering information on the patient's present illness, past medical history, family history, social history, allergies, and performing a physical examination. A provisional diagnosis may be made based on the information collected, but more information is needed to determine the actual diagnosis. The examination involves observing the patient and evaluating various body systems such as cardiovascular, respiratory, and neurological. Specific things to note include edema, pallor, koilonychia, cyanosis, clubbing, and jaundice.
This document outlines the process and components of taking a patient's medical history. It discusses introducing oneself to the patient, obtaining their chief complaint, history of present illness, past medical history, family history, drug history, and social history. It emphasizes listening to the patient, asking open-ended questions, avoiding medical terminology, and recording all information in the patient's own words. The goal is to accurately determine the etiology of the patient's illness based on their history.
The document provides guidance on history taking for pediatricians. It outlines the key attributes required of pediatricians including knowledge, skills, patience and compassion. It describes how to build rapport with children and parents through friendly behavior, making eye contact, and asking open-ended questions. The objectives and process of history taking are explained, with tips on listening actively and avoiding judgment. The document then details the various aspects of medical history to cover, such as presenting complaints, review of systems, past medical history, family history, and immunization status.
History Taking for Health Professionals, Nurses Pooja Koirala
This document provides guidelines for taking a patient's medical history. It outlines the key components of a history, including biographical information, chief complaints, history of present illness, past medical history, family history, and review of systems. The guidelines describe how to systematically collect information on symptoms, onset, severity, treatments received, and associated factors. Proper techniques for history taking are also covered, such as establishing rapport, active listening, maintaining privacy, and using a structured format to document the patient's history in a clear and organized manner.
This document provides an overview of the health assessment process, including the purpose, components, and guidelines for taking a patient's health history. The main points are:
- The purpose of a health assessment is to collect physical, mental, and social data about a client to identify problems, make clinical decisions, and evaluate outcomes of care.
- Taking a health history is a key part of the assessment process and involves systematically gathering both subjective data from the client and objective data observed by the nurse.
- There are several components that should be covered during a health history, including biographical data, chief complaints, history of present illness, past medical history, and family, social, and occupational information.
-
The document provides information on how to take a patient's medical history. It discusses the components of a medical history including:
1. Chief complaint - the patient's reason for visiting stated in their own words.
2. History of present illness (HPI) - details of the current illness including duration, severity, treatments tried, and associated symptoms.
3. Past medical history (PHM) - includes past illnesses, surgeries, medications, allergies, hospitalizations, and health maintenance.
4. Family history - focuses on hereditary illnesses in first and second degree relatives.
The document emphasizes using open-ended questions and following up with questions about duration, severity and other details to fully understand
Similar to historytaking for medical careers doctors medical students.pdf (20)
Strategies for Effective Upskilling is a presentation by Chinwendu Peace in a Your Skill Boost Masterclass organisation by the Excellence Foundation for South Sudan on 08th and 09th June 2024 from 1 PM to 3 PM on each day.
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LAND USE LAND COVER AND NDVI OF MIRZAPUR DISTRICT, UPRAHUL
This Dissertation explores the particular circumstances of Mirzapur, a region located in the
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advanced technologies such as GIS (Geographic Information Systems) and Remote sensing to
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cover support policymakers and scientists in making well-informed decisions, as alterations in
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Remote Sensing and Geographic Information Systems
9
Changes in vegetation cover refer to variations in the distribution, composition, and overall
structure of plant communities across different temporal and spatial scales. These changes can
occur natural.
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This presentation was provided by Steph Pollock of The American Psychological Association’s Journals Program, and Damita Snow, of The American Society of Civil Engineers (ASCE), for the initial session of NISO's 2024 Training Series "DEIA in the Scholarly Landscape." Session One: 'Setting Expectations: a DEIA Primer,' was held June 6, 2024.
2. What is History taking?
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
3. 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
4. • A large percentage of the time (70%),
you will actually be able make a
diagnosis based on the history alone.
5. How to take a history ?
“Always listen to the patient
they might be telling you the
diagnosis”. (Sir William Osler 1849 - 1919)
The basis of a true history is good communication
between doctor and patient.
It takes practice, patience, understanding and
concentration.
7. Introduce your self and create a rapport
Approach to history taking
8. Be alert and pay full attention
Approach to history taking
9. ► 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
10. “If in a bad mood or distracted
during the consultation, you can
end up making a history rather
than taking a history”.
11. Components of History taking
1. Patient’s profile
2. Chief complaint
3. History of the present illness
4. Past medical history
5. Family history
6. Socioeconomic history
7. System Review
12. 1. Patients profile
Date and Time
Name
Age
Sex
Religion
Marital status
Occupation
Address
Who gave the history?
13. 2. Chief complaint
The main reason for which the patient is trying to seek
medical help by visiting the physician.
Usually a single symptoms, occasionally more than
one complaints eg: fever, headache, pain, etc
The patient describe the problem in their own words.
It should be recorded in patients own words.
The complain should be recorded with their onset
duration
14. How to ask for chief complaint?
• What brings your here?
• How can I help you?
• What seems to be the problem?
If there is more than one complaint, it should be
written according to chronological order
2. Chief complaint
16. 3. History of the present illness
Elaborate on the chief complaint in detail
Ask relevant associated symptoms
Gain as much information you can about the specific
complaint.
Lead the conversation by asking questions.
Always start with an open ended question and take
the time to listen to the patient’s ‘story’.
Once the patient has completed their narrative then
closed questions can be asked to clarify .
Leading question are to be avoided.
17. Open questions allow patients to express their
own thoughts and feelings, 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 the answer
you want to hear.
3. History of the present
illness
18. In details of present problem with- time of onset/
mode of evolution/ any investigation;treatment
&outcome/any associated +’ve or -’ve symptoms.
Avoid medical terminology and make use of a
descriptive language that is familiar to patients
Sequential presentation
Always relay story in days before admission
Narrate in details
3. History of the present
illness
19. 3. History of the present
illness
Tips to gather information:
• S
• O
• C
• R
• A
• T
• E
• S
Site
Onset
Character
Radiation (of pain or discomfort)
Alleviating factors
Timing
Exacerbating factors
Severity (
20. 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
medicines given but says that he was told the medicine
would suppress his leg pains .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 and rigors with nausea
and vomiting.
3. History of the present
illness
21. 4. Past medical history
Any history of similar complaint in the past
Other medical problems the patient has or had
Any chronic disease present like hypertension,
diabetes etc
Past hospitalizations and past surgeries
Medications if any taken in the past (dosage and
duration)
Allergies
Pediatric: Birth history, Developmental
Milestones, Immunizations
Gyane/Obstetric history if female
22. 5. Family history
It is important to establish whether there are any
genetically transmitted diseases within families
Any illness run in thefamily?
Similar history in the family,
Parents and siblings suffering with any chronic illness,
Parents if died, how old and what they died of
You should be able to collect relevant family history
depending upon the present illness.
Example, Patient has come due anemia ,
Try to rule out sickle cell, thalasemia/ G6PD deficiency
23. 6. Socioeconomic history
Smoking history - amount, duration and type.
Drinking history - amount, duration and type
Any drug addiction
Sexual history if suspected STI
Occupation, social and education background,
financial situation
24. 7. System Review
Cardiovascular
•Chest pain
•Paroxysmal Nocturnal Dyspnoea
•Orthopnoea
•Short Of Breath
•Cough/sputum (
•Palpitations
•Cyanosis
Respiratory System
•Cough(productive/dry)
•Sputum (colour, amount, smell)
•Haemoptysis
•Chest pain
•SOB/Dyspnoea
•Tachypnoea
•Hoarseness
•Wheezing
General
•Weakness
•Fatigue
•Anorexia
•Change of weight
•Fever
•Lumps
•Night sweats
Gastrointestinal/Alimentary
•Appetite (anorexia/weight change)
•Diet
•Nausea/vomiting
•Regurgitation/heart burn/flatulence
•Difficulty in swallowing
•Abdominal pain/distension
•Change of bowel habit
•Haematemesis, melaena
•Jaundice
25. Urinary System
•Frequency
•Dysuria
•Urgency
•Hesitancy
•Terminal dribbling
•Nocturia
•Back/loin pain
•Incontinence
•Character of urine:color/
amount (polyuria) & timing
•Fever
Genital system
•Pain/ discomfort/ itching
•Discharge
•Unusual bleeding
Nervous System
•Visual/Smell/Taste/Hearing/
Speech
•Head ache
•Fits/Faints/Black outs/loss
of consciousness(LOC)
•Muscle weakness/ numbness/
paralysis
•Abnormal sensation
•Change of behaviour or psyche
Musculoskeletal System
•Pain – muscle, bone, joint
•Swelling
•Weakness/movement
•Deformities
7. System review
26. 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