History Taking

Assalamualaikum WBT.

Hi guys long time since the last update from TAPMED. Today I would like to talk about history taking. History taking from patients is important to reach a good diagnosis. We can't deny that nowadays there are lots of high-tech work up or investigation that can bring you to a diagnosis. However looking back to years back where there are no such investigation, history taking plays a big role in reaching a diagnosis. So waste no time and lets begin to talk about history taking from patients.

First of all when you are with a patient, make him comfortable and introduce yourself. Tell him/her why you are here. Shake hands if possible try to make the patient know that you are eager to help him/her.

Then start with:

Personal History

Name : Get their full name , if in Egypt get three names like Ahmad Mohammed Ibrahim

Age : Some diseases are age related

Sex :  Some diseases are sex related

Occupation : To look for occupational disease

Residence : Some disease are endemic in specific places

Habit : Special habit of medical importance such as smoking, alcohol intake.

Menstrual History for women : Regularity, Days of Cycle , Amount of bleeding

Complaint (c/o)

Ask the patient what brings him to the hospital.

Make sure that you are writing it down in patients own word. Exclude medical terms

As short as possible (one complaint is enough)

e.g. don't write epixstasis , but write "complaining of nose bleed"

don't forget to write the duration. e.g. complaining of chest pain for 2 days

History of Present Illness

Do it in chronological order. Ask when he was last healthy (symptomless). Write in medical terms.

Then analysis the complaint.

Then ask for symptoms of the related systems then proceed for other systems.

For every symptoms analysis for

Onset/Course/Duration

Association

What will increase or decrease the symptom

Effect of TTT if there is any

Date of last attack

For pain ask for site, radiation and character of the pain.

This is the part where you are playing a big role. Don't let the patient lead you, but you should lead the conversation for this part.

Past Medical History

Ask for any disease such as DM, HPT, TB, I.H.D

Ask for it's duration, manifestation, investigation, ttt and complication

Ask for any surgical history when ,where(site) and out come. Don't forget to ask if any blood transfusion.

Ask also if patients is taking any drugs for treatment.

Family History

Ask for consanguinity, Similar conditions or any related chronic disease like DM/HPT/TB/I.H.D.