principles of history taking
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Principles ofPrinciples of historyhistory takingtaking
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Reviewing the Chart:Reviewing the Chart:
TheThe medicalmedical chartchart givegive youyou valuablevaluable
informationinformation aboutabout pastpast diagnosisdiagnosis andand
treatmenttreatment YouYou shouldshould looklook atat thethe identifyingidentifying datadata
(age,(age, gender,gender, address,address, maritalmarital status,status,
healthhealth insurance,insurance, thethe medicationmedication list,list, thethe
documentationdocumentation ofof allergies)allergies)
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Clinicians BehaviorsClinicians Behaviors
AsAs youyou observeobserve thethe patientpatient throughtthrought thethe
interview,interview, thethe patientpatient willwill bebe watchingwatching youyou
You You shouldshould bebe sensitivesensitive toto thosethose messagesmessages
andand managemanage themthem asas wellwell asas youyou cancan
Posture,Posture, gesture,gesture, eyeeye contact,contact, andand wordswords cancan
expressexpress interest,interest, attention,attention, acceptance,acceptance, andand
understandingunderstanding TheThe skilledskilled interviewerinterviewer seemsseems calmcalm andand
unhurried,unhurried, eveneven whenwhen timetime isis limitedlimited
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Clinicians AppearanceClinicians Appearance
Cleanliness, neatness and a name
tag are reassuring to the patient.
Remember that you want the patient
to trust you
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Note takingNote taking
You need to write down much of what
you learn in a health history
The EnviromentThe Enviroment
Make the setting as private as possible
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Learning about the Patients iIlnessLearning about the Patients iIlness
Greeting the PatientGreeting the Patient
GreetGreet thethe patientpatient andand introduceintroduce yourselfyourselfbyby namename
IfIf thisthis isis thethe firstfirst contact,contact, clarifyclarify youryourrole,role, suchsuch asas statingstating youryour statusstatus asas aastudentstudent andand explainingexplaining youryour relationrelation toto
thethe patientspatients carecare WhenWhen otherother individualsindividuals areare present,present, askask
thethe permissionpermission ofof thethe patientpatient toto conductconductthethe interviewinterview inin frontfront ofof themthem
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The Patients ComfortThe Patients Comfort
Be alert to the patients comfort
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Comprehensive historyComprehensive history
Data and time of history: the date isData and time of history: the date is
importantimportant
Identifying data: including age, gender,Identifying data: including age, gender,maritual status and occupationmaritual status and occupation
Source of history: such as patient, family,Source of history: such as patient, family,
friend, officer, consultant, medical recordfriend, officer, consultant, medical record Chief complaintsChief complaints
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Comprehensive historyComprehensive history
Present illnesPresent illnes
Current medication: including dose andCurrent medication: including dose and
frequency of usefrequency of use AllergiesAllergies
Past historyPast history
Childhood illnesses: such as measles,Childhood illnesses: such as measles,rubella, mumps, whooping cough, chickenrubella, mumps, whooping cough, chicken
pox, rheumatic fever, poliopox, rheumatic fever, polio
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Comprehensive historyComprehensive history
Adult illnesses:Adult illnesses:
MedicalMedical
1.1. Diabetes mellitusDiabetes mellitus2.2. HypertensionHypertension
3.3. HepatitisHepatitis
4.4. AsthmaAsthma
5.5. HIVHIV
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Comprehensive historyComprehensive history
Adult illnesses:Adult illnesses:
Surgical: include dates, indication, outcomeSurgical: include dates, indication, outcome
Obstetric/ Gynecologic: inculde obstetricObstetric/ Gynecologic: inculde obstetrichistory, menstruation history, birth control,history, menstruation history, birth control,
number and gender of partners, atnumber and gender of partners, at--riskrisk
practisespractisesPsychiatric: include dates, diagnosis,Psychiatric: include dates, diagnosis,
hospitalisations, treatmenthospitalisations, treatment
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Current health statusCurrent health status
Tobacco (type used, amount and duration ofTobacco (type used, amount and duration of
use)use)
Alcohol (type used, amount and duration ofAlcohol (type used, amount and duration of
use)use)
Drugs (type used, amount and duration ofDrugs (type used, amount and duration of
use)use)
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Current health statusCurrent health status
Exercise and dietExercise and diet
Immunisations:Immunisations:
1.1. TetanusTetanus
2.2. PertussisPertussis
3.3. DiphteriaDiphteria
4.4. PolioPolio
5.5. MeaslesMeasles
6.6. RubellaRubella7.7. MumpsMumps
8.8. InfluenzaInfluenza
9.9. Hepatitis BHepatitis B
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Family historyFamily history
Age and health, or age and couse of death ofAge and health, or age and couse of death of
each immediate family members (parents,each immediate family members (parents,
siblings, spouse, and children)siblings, spouse, and children)
Date of grandparents and grandchildrenDate of grandparents and grandchildren
may also be usefulmay also be useful
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Family historyFamily history
Diabetes mellitusDiabetes mellitus
Heart diseaseHeart disease
HypercholeterolemiaHypercholeterolemia High blood pressureHigh blood pressure
StrokeStroke
Kidney diseasesKidney diseases
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Family historyFamily history
ArthritisArthritis
AnemiaAnemia
AllergiesAllergies AsthmaAsthma
HeadachesHeadaches
Mental illnessMental illness
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Family historyFamily history
TuberculosisTuberculosis
CancerCancer
DrugsDrugs EpilepsyEpilepsy
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Personal and Social HistoryPersonal and Social History
Occupation and educationOccupation and education
Home situationHome situation
Daily lifeDaily life
Leisure activites/hobbiesLeisure activites/hobbies
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Present illnessPresent illness
The principal symptoms should be discribed inThe principal symptoms should be discribed interms of:terms of:
1.1. LocationLocation2.2. QualityQuality
3.3. Quantity and severityQuantity and severity
4.4. TimingTiming
5.5. Factors that have aggrevated or relievedFactors that have aggrevated or relieved
themthem
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Review of systemsReview of systems
General:General:
Weight, recent weight changeWeight, recent weight change
WeaknessWeakness FatiqueFatique
FeverFever
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Review of systemsReview of systems
Skin:Skin:
Rashes,Rashes,
lumps,lumps, sores,sores,
itching,itching,
dryness,dryness, color changecolor change
Hair and nails changesHair and nails changes
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Review of systemsReview of systems
HeadHead: headache, head injury, dizziness: headache, head injury, dizziness
EyesEyes: vision, glasses, contact lenses, pain,: vision, glasses, contact lenses, pain,
redness, dryness, double vision, spots,redness, dryness, double vision, spots,flashing lights, glaucoma, cataractaflashing lights, glaucoma, cataracta
EarsEars: hearing, vertigo: hearing, vertigo
Nose an sinusesNose an sinuses: frequent cold, nasal: frequent cold, nasalstuffiness, hay fever, sinus troublestuffiness, hay fever, sinus trouble
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Review of systemsReview of systems
Mouth and throutMouth and throut: condition of teeth, gums, bleeding: condition of teeth, gums, bleedinggums,sore tonque, dry mouth, frequnt sore throats,gums,sore tonque, dry mouth, frequnt sore throats,hoursenesshourseness
NeckNeck: lumps, swollen glands,goiter pain: lumps, swollen glands,goiter pain
BreastBreast: lumps, pain and discomfort: lumps, pain and discomfort
RespiratoryRespiratory: cough, sputum (color quantity): cough, sputum (color quantity)
hemoptysis, dyspnea, wheezing, asthma, bronchitis,hemoptysis, dyspnea, wheezing, asthma, bronchitis,emphysema, pneumonia, tuberculosisemphysema, pneumonia, tuberculosis,,
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Review of systemsReview of systems
CardiacCardiac::
heart trouble,heart trouble,
high blood pressure,high blood pressure, rheumatic fever,rheumatic fever,
heart murmurs,heart murmurs,
chest pain or discomfort,chest pain or discomfort, palpitations, dyspnoe, orthopnoe,palpitations, dyspnoe, orthopnoe,
paroxysmal nocturnal dyspnoe, edemaparoxysmal nocturnal dyspnoe, edema
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Review of systemsReview of systems
GastrointestinalGastrointestinal::
Trouble swallowingTrouble swallowing
HeartburnHeartburn AppetiteAppetite
NauseaNausea
VomitingVomiting RegurgitationRegurgitation
Vomiting of bloodVomiting of blood
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Review of systemsReview of systems
GastrointestinalGastrointestinal::
Bowel movementsBowel movements
Color and size of stoolsColor and size of stools
Change of bowel habitsChange of bowel habits
Rectal bleedingRectal bleeding
Black tarry stoolsBlack tarry stools
HemorrhoidsHemorrhoidsConstipationConstipation
DiarrheaDiarrhea
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Review of systemsReview of systems
Gastrointestinal:Gastrointestinal:
Abdominal painAbdominal pain
Food intoleranceFood intoleranceJaundiceJaundice
Liver or gallbladder troubleLiver or gallbladder trouble
hepatitishepatitis
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Review of systemsReview of systems
Urinary:Urinary:
Frequency of urinationFrequency of urination
PolyuriaPolyuria
NocturiaNocturia Burning or pain on urinationBurning or pain on urination
HematuriaHematuria
UrgencyUrgency
Reduces caliber or force if the urinary streamReduces caliber or force if the urinary stream IncontineceIncontinece
stonesstones
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Review of systemsReview of systems
GenitalGenital::
Female:Female:
Age at menarcheAge at menarche RegularityRegularity
FrequencyFrequency
Duration of periodsDuration of periods Amount of bleedingAmount of bleeding
Last periodLast period
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Review of systemsReview of systems
Genital:Genital:
Femal:Femal:
DysmenorrheaDysmenorrhea
Premenstrual tensionPremenstrual tension Age at menopausaAge at menopausa
ItchingItching
Sexually transmitted diseasesSexually transmitted diseases
Number of pregnanyciesNumber of pregnanycies Number and type of deliveryNumber and type of delivery
Number of abortionNumber of abortion
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Review of systemsReview of systems
Genital:Genital:
Male:Male:
HerniasHernias Testicular painTesticular pain
Sexually transmitted diseasesSexually transmitted diseases
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Review of systemsReview of systems
Periferla vascular:Periferla vascular:
Intermitten claudicationIntermitten claudication
Leg crampsLeg cramps Varicose veinsVaricose veins
Past clots in the veinsPast clots in the veins
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Review of systemsReview of systems
Musculoskeletal:Musculoskeletal:
Muscle pain, weaknessMuscle pain, weakness
Joint painJoint pain StiffnessStiffness
ArthritisArthritis
GoutGout
BackacheBackache
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Review of systemsReview of systems
Neurologic:Neurologic:
1.1. SeizeresSeizeres
2.2. WeaknessWeakness3.3. ParalysisParalysis
4.4. Numness or loss of sensationNumness or loss of sensation
5.5. TremorTremor
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Review of systemsReview of systems
HematologicHematologic
AnemiaAnemia
Easy bruising or bleedingEasy bruising or bleeding Past transfusionPast transfusion
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Review of systemsReview of systems
EndocrineEndocrine
Thyroid troubleThyroid trouble
Heat or cold intoleranceHeat or cold intolerance Excessive sweatingExcessive sweating
DiabetesDiabetes
Excessive thirst or hungerExcessive thirst or hunger
polyuriapolyuria
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Establishing RapportEstablishing Rapport
TheThe initialinitial contactcontact withwith thethe patientpatient setssets thethe foundationfoundationforfor thethe relationshiprelationship
GoodGood interviewinginterviewing techniquetechnique allowsallows patientspatients totorecountrecount theirtheir ownown storiesstories spontaneouslyspontaneously
You You shouldshould listenlisten activelyactively andand watchwatch forfor cluesclues totoimportantimportant symptoms,symptoms, emotionsemotions events,events, andandrelationshipsrelationships
YouYou cancan thanthan guideguide thethe patientpatient intointo tellingtelling youyou moremore
aboutabout thethe areasareas thatthat seemseem mostmost significantsignificant.. ThisThis isis donedone byby usingusing directdirect questioningquestioning
QuestiontsQuestionts shouldshould proceedproceed fromfrom thethe generalgeneral toto thethespecificspecific
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Sometimes patients seem quite unable to describeSometimes patients seem quite unable to describetheir symptoms without helptheir symptoms without help
Offer multipleOffer multiple--choice answerschoice answers Is your pain Is your pain achingaching,,sharp, pressing, burning, shooting, or whatsharp, pressing, burning, shooting, or what??
Use lanquage that is undestandable and appropiate toUse lanquage that is undestandable and appropiate to
the patientthe patient Establishing the sequence and time course of theEstablishing the sequence and time course of the
patients symptoms is importantpatients symptoms is important
You can encourage a chronologic account by suchYou can encourage a chronologic account by suchquestions asquestions as What thanWhat than? or ? or What happened nextWhat happened next??
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Generating and TestingGenerating and Testing
Diagnostic HypothesesDiagnostic Hypotheses AsAs youyou learnlearn aboutabout thethe patientspatients storystory
andand thethe symptoms,symptoms, youyou shouldshould bebegeneratinggenerating hypotheseshypotheses aboutabout whatwhat bodybody
systemssystems mightmight bebe involvedinvolved byby aapathologicpathologic processprocess
ForFor example,example, legleg pain,pain, suggestssuggests aaproblemproblem inin thethe peripheralperipheral vascular,vascular,musculoskeletal,musculoskeletal, oror nervousnervous systemsystem
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11.. ItsIts locationlocation..WhereWhere isis it?it? DoesDoes itit radiate?radiate?
22.. ItsIts qualityquality.. WhatWhat isis itit like?like?
33.. ItsIts quantityquantity oror severityseverity.. HowHow badbad isis it?it?
44.. ItsIts timingtiming.. WhenWhen diddid oror doesdoes itit start?start?
HowHow longlong doesdoes itit last?last? HowHow oftenoften doesdoes ititcome?come?
55.. TheThe settingsetting inin whichwhich itit occurs,occurs, includingincludingenviromentalenviromental factors,factors, personalpersonal activities,activities,
emotionalemotional reactionsreactions.. 66.. FactorsFactors thatthat makemake itit betterbetter oror worseworse..