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History Taking
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Why do we take history from the patient?
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What would happen if we do not make a diagnosis?
or if we made the wrong diagnosis?
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How do we take history?
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Set up of history taking
In the outpatient clinicIn the inpatient clinic
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Components of the History
The present complaintThe history of the present complaintRemaining questions of abnormal systemReview of systemsPast medical history
Past surgical historyDrug history
Immunizations
Family historySocial history & habits
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ALWAYS
INTRODUCE YOURSELF TO THE PATIENT AND EXPLAIN TO HIM OR HER WHAT YOU ARE GOING TO DO. GET A CHAPERON WHEN YOU INTERVIEW A FEMALE PATIENT.
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ALWAYS RECORD PATIENT’S
NameAgeSexMarital statusOccupationAddressDate of interview
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1-Present complaint
In patient’s own words with duration.“What are you complaining of?”“What is the problem?”“What is the matter?”
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2-History of the present complaint
EXAMPLE: ABDOMINAL PAINSiteTime and mode of onsetNatureDurationSeverity
RadiationProgression/endRelieving factorsExacerbating factorsCause
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3-Remaining questions of abnormal system
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Is it time to make a provisional diagnosis?
What is a diagnosis?
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Diagnosis
Any diagnosis consists of Anatomical part + Pathological
partExamples:
Breast cancerPeptic ulcerFracture femur
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Differential diagnosis or working diagnosis
Most likely why?Less likely why?Least likely why?
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4-Review of systems
The Gastro-intestinal systemThe Respiratory systemThe Cardiovascular systemThe Urogenital systemThe Nervous systemThe Musculoskeletal system
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Gastro-intestinal system
AppetiteDietWeightTeeth and tasteSwallowingRegurgitationFatulance
HeartburnVomitingHaematemesisAbdominal PAINAbdominal distensionDefecationChange of color of skin
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The Respiratory system
CoughSputumHaemoptysisDyspnoeaOrthopnoeaChest pain
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The Cardiovascular system
CHEST PAINDyspnoeaOrthopnoeaPalpitationsCough and sputumDizziness and headacheAnkle swellingPeripheral vascular symptoms
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The Urogenital system
PainOedemaThirstMicturitionUrine
Scrotum and urethraMenstruationPregnanciesBreastsSecondary sex characteristics
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The Nervous system
Mental stateConscious levelFitsTIAS= transient ischemic attacksLoss of sensationsParaesthesiae (pins and needles)
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The musculoskeletal system
PainSwellingLimitation of movements of any joint
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5-Past medical history
Any hospitalizationTB = TuberculosisDM = Diabetes mellitusAsthmaRheumatic feverContact with patients with hepatitis or aids
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6-Past surgical history
Previous operationsBlood transfusionAny complications with anesthesiaBleeding tendencies
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7-Drug history
SteroidsInsulinAntihypertensive drugsHormone replacement therapy
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8-Immunizations
DPT = diphtheria, pertussus, tetanusMeaslesMumpsRubellaPoliomyelitisTBSmallpoxTyphoid
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9-Family history
Health and age or cause of death of patient’s parents ,brothers and sisters
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10-Social history & habits
Marital statusHazards of occupationSocial status- type of residenceTravel abroad-datesSmokeDrinksAny unusual?
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Summary
Patient’s name, age and sex.Complaint and the most important positive characteristics of his/her complaintThe most important negative features of his complaint.
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Analysis of the differential diagnosis
Review the list you made earlier
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What have we gained from the history taking?
To make a diagnosisTo formulate a complete picture about this patient which will enable you to plan his or her management
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THANK YOU