Basics of history taking in medicine

1,390 views

Published on

History taking in medicine is one of the challenge all medical students face. This brief guide was prepared based on the teachings of Prof.A.S.B.Wijekoon, Prof.I.Amarasinghe & many senior registrars/registrars met during my career. This explans the basics of what must be included in your history, how to plan your investigations/ treatment in a methodical way.

Published in: Health & Medicine
0 Comments
3 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
1,390
On SlideShare
0
From Embeds
0
Number of Embeds
3
Actions
Shares
0
Downloads
48
Comments
0
Likes
3
Embeds 0
No embeds

No notes for slide

Basics of history taking in medicine

  1. 1. History taking in medicine 1. P/C Symptom X duration e.g. Abdominal pain for 1 day 2. There are ONLY 5 symptoms 1. Pain 2. ∆ Temperature 3. ∆ Shape: lump 4. Leakage of body fluids: h’rrhage 5. Loss of function 3. 4. DD Diseases could be either Congenital Acquired 1. Infective 2. Inflammatory 3. Neoplastic 4. Traumatic 5. Degenerative 6. Metabolic/ autoimmune 7. Vascular 5. Symptom: History of presenting complain must have following 1. Perspective i. Entirely new disease ii. New symptom of ongoing disease iii. Iatrogenic 2. Symptom analysis 3. Evolution, interventions 4. System review 5. Conclusion: current status, SOAP i. Subjective ii. Objective iii. Assessment-overall iv. Plan 5 components of diagnosis 1. Anatomy 2. Temporal nature (acute /chronic/ acute on chronic) 3. Pathology 4. Etiology 5. complications/severity/extent Problems Medical: acute/ chronic 1. Illness/∆ a. Complications i. Organ ii. Distal organ iii. General 2. Risk of illness 3. Socio-economic Non-medical To the patient To the family Investigations Plan your investigations to Confirm diagnosis a. Anatomy: CXR b. Pathology: CRP c. Etiology: culture Risk factors a. Modifiable b. Non-modifiable Complications a. Immediate b. Late c. Iatrogenic Assessment of progression a. TPR/ symptom chart Prognosis Your investigations could be Lab a. Hematological b. Urine c. Stools d. CSF e. Other swabs f. Biopsy: BM, skin Imaging a. USS b. Xray c. MRI/CT Minimally invasive: Endoscopy Mx 1. 2. 3. 4. 5. Symptomatic Supporting a. Feeding/fluid b. Micturition c. Bowel d. Sleep/rest/activity Specific a. Anatomy b. Pathology c. Etiology Prevention a. Iry, notification IIry, IIIry Rehabilitation Pharmacological Non- pharmacological Mx of malignancy 1. Diagnosis a. Gross anatomical b. Histological 2. Staging a. Distal METS 3. Assess other systems a. Lung, liver, kidney, brain, 4. Optimization a. Nutrition 5. Treatment a. Curative i. Medical ii. Minimally invasive iii. Surgical b. Palliative Yapa Wijeratne M/07/189

×