Download Why history taking is important

HISTORY TAKING
DEFINITION
• A case history is defined as a planned
professional conversation that enables the
patient to communicate his/her symptoms,
feeling and fear to the clinician so as to obtain
an insight into the nature of the patients illness
and his/her attitude to them
WHY HISTORY TAKING IS IMPORTANT
• To establish a diagnosis
• Detect medical problems
• Evaluate other systemic problems
• Discovery of communicable diseases
• Management of emergencies
• For effective treatment plan
DIAGNOSIS OCCURS THROUGH
• Taking and recording case history
• Physical examination
• Request relevant investigations
• Establish a diagnosis
• Outline management step
• Prognosis and clinical evaluation of the most
probable outcome of therapy
TASKS TO BE ACHIEVED BY PHYSICIAN IN
HISTORY TAKING
1. Build a relationship with the patient.
2. Learn about the patient as a person.
3. Help the patient with the emotional aspects of the
illness.
4. Help the patient learn about health, illness and
health care options.
5. Choose an appropriate course of action with the
patient.
6. Help the patient plan and carry out the chosen
action.
7. Understand the impact of the illness on the patient
and his/her family.
8. Define the patient’s understanding of his/her illness
nd attitudes in regard to evaluation and treatment
BEFORE START HISTORY TAKING
• Introduce Yourself to the Patient
• Put the Patient at Ease
• Establish eye contact
• Your approach to the patient should be gentle,
sympathetic, friendly and confident
• Listen to the patients concerns and then ask
questions about aspects that remain deficient
• If interruption is necessary it should be timed
and planned
• Encourage the patient to give details of his
symptoms and don’t use of medical terms
• Avoid writing when the patient is talking, this will
give the impression that you are not listening
• Write the history in order and avoid jargon
SEQUENCE OF HISTORY TAKING
• Personal data
• Chief complain
• History of presenting illness
• Systemic review
• Past medical history
• Family history
• Social history
• Drug history
A. PERSONAL DATA
• Name:
• Identification
• For communication
• For rapport with the patient
• Record maintenance
• Age:
• Certain disease occurs at different age groups
e.g. measles is common in children. Myocardial
infarction is common in old patients
• Gender:
• Some diseases occurs more common in one particular
sex. E.g. SLE is more common in female
• Address:
• For future contact
• Give view of socioeconomic status
• Prevalence of the disease
• Occupation:
• Assess the socioeconomic status of the patient
• Predilection of disease in different occupations e.g.
hepatitis in nurses and dentist, lung fibrosis in industrial
workers
CHIEF COMPLAIN
• The chief complain is established by asking the
patients to describe the problem they seek medical
help for.
• It is recorded in the patients own words and no
medical or technical language is used
• It is recorded in a chronological order of their
appearance
• Chest pain / 2 months
• Fever
/
1month
• Vomiting / 2 days
• The chief complain aids in the diagnosis and
treatment planning and should be given the first
priority
HISTORY OF PRESENTING ILLNESS
• Initially the patient may not volunteer the detailed
history of the problem so the examiner has to elicit
additional information by asking closed ended
questions
• Analyze each complain in details
• Ask about other relevant symptoms to the
system involved
• Patients tends to forget 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 cardinal symptoms of
each systems.
SYSTEMS REVIEW
General wellbeing:
• weight (gained, lost or static), appetite (good, poor),
fever (duration, grade, pattern, reliving and
aggravating factors, associated with chills, rigor,
sweats. headache), fatigue
NS:
• loss of consciousness, headache (Onset, Site,
timing, Continuous/ intermittent, Nature, Duration,
Severity, Reliving and aggravating factors,
Progression, Associated features) , dizziness,
weakness (onset, site, course, complete or
incomplete paralysis, static or progressive),
• convulsion
(frequency,
aura,
loss of
consciousness, generalized/ localized, tonic
clonic/rigidity, tongue biting, urinary and fecal
incontinence, fall/trauma, duration of the attack,
after the attack the patient had any symptoms
e.g. headache, paralysis, went to deep sleep, do
the attacks come during sleep),
• Tremor, sensory loss, numbness, tingling
sensation, symptoms related to cranial nerve
palsy
Cardiopulmonary:
• Cough (duration, frequency, more at day/night, dry or
productive, sputum “amount, color, smell, blood), chest
pain (Onset, Site, timing, Continuous/ intermittent,
Nature, Duration, Severity, Radiation, Reliving and
aggravating factors, Progression, Associated features),
SOB (grade), PND, orthopnia, palpitation (duration,
awareness, onset, associated symptoms) ,
haemoptysis, wheeze, syncope
GIT:
• indigestion (dyspepsia), gas, heartburn, nausea,
vomiting (duration, frequency, projectile or not,
amount, color, smell, content of the vomitus,
haematamesis, relation to food), abdominal pain
(Onset, Site, timing, Continuous/ intermittent, Nature,
Duration, Severity, Radiation, Reliving and
aggravating factors, Progression, Associated
features),
abdominal
distension
(site,
generalized/localized progression)
• hematemesis, melena, stool, constipation
(frequency, duration, normal bowel habits, blood,
alternating bowel habits, eating habits), diarrhea
(duration, frequency, amount, consistency, blood
or mucus, tenesmus, severity, associated
symptoms), jaundice, hematochezia.
GU:
• loin pain (Onset, Site, timing, Continuous/
intermittent, Nature, Duration, Severity,
Radiation, Reliving and aggravating factors,
Progression, Associated features), frequency
(nocturia, polyuria) prostatism (urgency,
hesitance,
dripping,
urinary
retention),
incontinence, dysuria, hematuria. Menstrual
cycle in female
Musculoskeletal:
• Rashes, itching, changes in hair, bruising, joint
pain (joints affected, sequence of involvement,
joint swelling, relation with movement), swelling,
morning stiffness, lower limb edema (site,
progression)
PAST MEDICAL HISTORY
• Past history of similar condition
• Hospitalization , surgeries, blood transfusion
• All disease suffered by the patient should be recorded
in chronological order
• The patient should be assessed by direct open and
closed ended questions
• Whether he is suffered from any major systemic
illness (diabetes, hypertension, heart disease,
asthma, epilepsy)
• Ask specifically about certain disease relevant
to the patients history
• Ask about history of contact especially in
infectious diseases
FAMILY HISTORY
• The health of the entire family, living and dead with
particular attention to the possible genetic and
environmental determinants of disease
• Family history of similar condition
• Major disease (diabetes,
disease, asthma, epilepsy)
hypertension,
heart
SOCIAL HISTORY
• Marital status
• Smoking
• Alcohol
• Financial support
• Availability of support
• Impact of the disease: ability to work, coping
with daily activities, personal relationship
• Housing: flat. Stairs, modification, pets
• Hobbies
• Travel
• Immunization and prophylaxis
DRUG HISTORY
• If the patient does not remember the name of
medications ask if he has any with him now or old
prescription
• Write down the name, dosage, duration of therapy,
compliance,
• Long term medication
• Current medications
• Adverse reactions
• allergies