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History Taking PDF

This document outlines the steps for taking a patient's history, including introducing yourself, gathering biographical data, recording the presenting complaint, reviewing the history of the presenting complaint with follow up questions, reviewing relevant body systems, and gathering the patient's past medical, surgical, family, personal, socioeconomic, drug, and immunization histories. The goal is to gain a comprehensive understanding of the patient's current issues and overall health status in order to make an accurate diagnosis.

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51 views2 pages

History Taking PDF

This document outlines the steps for taking a patient's history, including introducing yourself, gathering biographical data, recording the presenting complaint, reviewing the history of the presenting complaint with follow up questions, reviewing relevant body systems, and gathering the patient's past medical, surgical, family, personal, socioeconomic, drug, and immunization histories. The goal is to gain a comprehensive understanding of the patient's current issues and overall health status in order to make an accurate diagnosis.

Uploaded by

Ali
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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HISTORY TAKING

1)-Introduction and Rapport building


Introduce yourself, identify your patient and gain consent to ask questions regarding the disease.

2)- Biodata
Name, age, gender, residence, occupation, religion, date of admission, mode of admission

3)- Presenting Complaint


These are the symptoms or signs which made the patient come to the hospital. Record them in chronological
order, i.e. write the complaint which developed first at the top followed by other complaints in the sequence of
occurrence. Write duration of each complaint in front of it for e.g.
Pain in the right iliac fossa → 48 hours, nausea and vomiting → 12 hours, anorexia→ 12 hours

4) - History of presenting complaint


Gain as much information you can about all the complaints.
For RIF pain as an example, you should ask:
• Site: Where exactly is the pain?
• Onset: When did it start, was it constant/intermittent, gradual/ sudden?
• Character: What is the pain like e.g., sharp, burning, colicky, stabbing, pricking, constricting.
• Radiation: Does it radiate/move anywhere?
• Associations: Is there anything else associated with the pain, e.g., nausea, vomiting, diarrhoea.
• Time course/timing: Does it follow any time pattern, how long did it last?
• Exacerbating / relieving factors: Does anything make it better or worse?
• Severity: How severe is the pain, consider using the 1-10 scale?
The SOCRATES acronym can be used for any type of pain history.
If a symptom has been occurring again and again and is present in this admission as well, mention this in the
history of presenting illness.

REVIEW OF THE RELEVANT SYSTEMS /SYSTEMIC REVIEW / SYSTEMIC INQUIRY/ SYSTEMIC DIRECT
QUESTIONS
A full systems review should not be asked from every patient. You should ask the system reviews relevant to the
presenting complaint to determine the presence/absence of any possible associated symptoms. This should be
done as part of the history of presenting complaints section. e.g. for left iliac fossa pain, after asking questions
about the pain, you should ask gastrointestinal, urological and, if female, obstetric and gynaecological systems
questions. You must ask further symptom-specific questions for each positive symptom.
General
Fever, rigors, night sweats, weight loss, fatigue, skin rashes, bruising
Gastrointestinal
Weight loss or weight gain, appetite change, dysphagia, odynophagia, anorexia, nausea, vomiting, indigestion,
heartburn, abdominal pain, abdominal distension, change in bowel habits, flatulence, haematemesis, Jaundice,
bowel habits, nature of stool, blood or mucus in the stool, prolapse, faecal incontinence, tenesmus.
Urological
In Males: Loin pain, frequency of micturition, urgency, nocturnal frequency, hesitancy, poor stream, dribbling,
dysuria, haematuria, precipitancy, polyuria, thirst, urinary incontinence, problems with sexual intercourse and
impotence.
In females: Frequency of urination, urinary incontinence and vaginal discharge.
Obstetric and Gynaecological
Length of menstrual cycle, quantity of blood loss in each cycle, vaginal discharge, dysmenorrhoea, dyspareunia,
previous pregnancies and their complications, uterine prolapse, breast pain, nipple discharge and lumps.
Respiratory system
Cough, Sputum, haemoptysis, dyspnoea, hoarseness, wheezing, chest pain, exercise tolerance.
Cardiovascular system
Chest pain, dyspnoea, palpitations, Paroxysmal nocturnal dyspnoea, Orthopnoea, ankle swelling, dizziness, limb
pain, walking distance, colour changes in hands and feet.
Central nervous system
Changes of behaviour, depression, memory loss, delusions, anxiety, tremors, syncopal attacks, loss of
consciousness, fits, muscle weakness, paralysis, sensory disturbances, paraesthesia’s, dizziness, changes of
smell, vision or hearing, tinnitus, headache.
Musculoskeletal system
Aches or pains in muscles, bones or joints, Swelling in the joints, limitation of joint movements, locking,
weakness, disturbances of gait.

5)- Past Medical History


Gather information about a patient’s other medical problems. Ask about Diabetes mellitus, Hypertension,
Ischemic heart disease, Asthma, Tuberculosis, Hepatitis, bleeding tendencies, Cancers, sexually transmitted
diseases and tropical diseases.

6)- Past Surgical History


Record any past surgical procedures with their dates and where they were performed

7) - Family History
Gather information about the patient’s family history. Ask about diabetes mellitus, Hypertension, Ischemic heart
disease, Asthma, Tuberculosis, Hepatitis, bleeding tendencies, Cancers, any genetic conditions within the family,
for example: polycystic kidney disease.

8)- Personal history


Diet, smoking (number of cigarettes smoked per day), Alcohol intake, another kind of addiction, sleeping
habits.

9)- Socioeconomic history


Monthly income, ask about residence, family members and any other sources of income.

10)- Obstetric and Gynaecological History


Length of menstrual cycle, quantity of blood loss in each cycle, vaginal discharge, dysmenorrhoea,
dyspareunia, previous pregnancies and their complications, uterine prolapse, breast pain, nipple discharge and
lumps

11)- Drug History


Find out what medications the patient is taking, including dosage and how often they are taking them, for
example: once-a-day, twice-a-day, etc.

12)- Allergies
Drug allergies, latex allergies and food allergies.

13)- Immunization status


BCG, Diphtheria, Tetanus, Hepatitis, Typhoid, Measles.

DR. WASIF MAJEED CHAUDHRY


Associate Professor, General Surgery, LMDC

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