The document discusses the importance of medical history taking in diagnosing patient conditions, emphasizing that patients present with symptoms rather than diagnoses. Key components of history taking include the introduction, presenting complaint, and various medical histories including past medical and surgical details, drug history, family history, and social history. Each component is essential for understanding the patient's condition and its underlying causes.

1. Medical History Taking
Kavya Liyanage

2. Why medical history taking is important?
▪ Patients do not come to the doctor with the diagnosis, but with
symptoms.
▪ In order to diagnose what the patient has, we need to get a good
relevance history of the patient.
▪ Also, history taking helps to find the cause for the patient’s condition.

3. Main Components of History Taking
▪ Introduction
▪ Presenting complaint
▪ History of presenting complaint
▪ Past medical history
▪ Past surgical history
▪ Drug history and allergies
▪ Family history
▪ Social history

4. Introduction
▪ Name
▪ Age
▪ Occupation
▪ Residence

5. Presenting complaint
▪ This should be in the patient’s words.
▪ Symptoms and their duration

6. History of presenting complaint
▪ Onset, nature, course and duration of each symptom
▪ When describing a pain, characteristics of pain is described as
SOCRATES
– Site
– Onset
– Character
– Radiation
– Associated features
– Timing (duration, course, pattern)
– Exacerbating and relieving factors
– Severity

7. Past medical history
▪ Medical details related to the current complaint
▪ Important negatives also should be mentioned

8. Past surgical history
▪ Previous surgical procedures that the patient had undergone.
▪ The type of anaesthesia used and any complications

9. Drug history and allergies
▪ Significant drugs that the patient has been using
▪ Allergies

10. Family history
▪ Family history about relevant diseases that can be transmitted
genetically to the patient

11. Social history
▪ Whether the type of living of the patient has an impact on the patient’s
condition
▪ Occupation
▪ Marital status
▪ Living circumstances
▪ Smoking
▪ Alcohol
▪ Illicit drug use
▪ Family support

12. Thank You!