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    History Taking

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    JAMES TONNY OKINYI
    History taking involves physicians obtaining information from patients through directed questioning to aid in diagnosis and treatment. It is the most important first step, with 70% of diagnoses made based on history alone. Effective history taking requires active listening to fully understand the patient's story and symptoms, asking open-ended questions, and considering all aspects of the patient's medical, family, and social history.

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    History Taking

    Uploaded by

    JAMES TONNY OKINYI
    150 views51 pages
    History taking involves physicians obtaining information from patients through directed questioning to aid in diagnosis and treatment. It is the most important first step, with 70% of diagnoses made based on history alone. Effective history taking requires active listening to fully understand the patient's story and symptoms, asking open-ended questions, and considering all aspects of the patient's medical, family, and social history.

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    History taking involves physicians obtaining information from patients through directed questioning to aid in diagnosis and treatment. It is the most important first step, with 70% of diagnoses made based on history alone. Effective history taking requires active listening to fully understand the patient's story and symptoms, asking open-ended questions, and considering all aspects of the patient's medical, family, and social history.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    150 views51 pages

    History Taking

    Uploaded by

    JAMES TONNY OKINYI
    History taking involves physicians obtaining information from patients through directed questioning to aid in diagnosis and treatment. It is the most important first step, with 70% of diagnoses made based on history alone. Effective history taking requires active listening to fully understand the patient's story and symptoms, asking open-ended questions, and considering all aspects of the patient's medical, family, and social history.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 51
    At a glance
    Powered by AI
    The key takeaways are that obtaining an accurate medical history is important for diagnosis, a history can provide 70% of the diagnosis, and listening to the patient is critical.

    Obtaining an accurate history is the critical first step in determining the cause of a patient's illness. It is one of the bases of making a diagnosis along with physical examination and investigations.

    The components of a medical history include the patient's profile, chief complaint, history of present illness, past medical history, family history, socioeconomic history.

    History taking

    What is History taking?


    It is a process by which information is gained by a physician
    by asking specific questions to the patient with the aim of
    obtaining information useful in formulating a diagnosis and
    providing medical care to the patient
    Importance of History Taking?
    Obtaining an accurate history is the critical first step in
    determining the etiology of a patient's illness.
    Diagnosis in medicine is based on
    Clinical history
    Physical Examination
     Investigations
    A large percentage of the time (70%), you will actually be able
    make a diagnosis based on the history alone.
    How to take a history ?
    “Always listen to the patient they might be telling you the
    diagnosis” . (Sir William Osler 1849 - 1919) The basis of a
    true history is good communication between doctor and
    patient. It takes practice, patience, understanding and
    concentration.
    Always listen to the patient they might be telling you
    the diagnosis” . (Sir William Osler 1849 - 1919)
    A large percentage of the time (70%), you will
    actually be able make a diagnosis based on the history
    alone.
    How to take a history ?
     “Always listen to the patient they might be telling you the
    diagnosis” . (Sir William Osler 1849 - 1919)
    The basis of a true history is good communication between
    doctor and patient.
    It takes practice, patience, understanding and concentration.
    “Always listen to the patient they might be
    telling you the diagnosis” . (Sir William
    Osler 1849 - 1919)
    Approach to history taking

    Your look is important


     Your dressing
    Good look and dressing
    Bad dressing and poor look
    Introduce your self and create a rapport
    If it is culturally appropriate
    Be alert and pay full attention like this (Good
    attention)
    Good attention
    Poor attention
    Poor attention
    Approach to history taking
    Ensure consent has been gained.
    Maintain privacy and dignity.
    Ensure the patient is as comfortable as possible
    Summarize each stage of the history taking process.
    Involve the patient in the history taking process
    “If in a bad mood or distracted during the
    consultation, you can end up making a
    history rather than taking a history”.
    Components of History taking
    Patient’s profile
    Chief complaint
    History of the present illness
    Past medical history
    Family history
    Socioeconomic history
     System Review
    Patients profile
    Date and Time Name Age Sex
     Religion Marital status Occupation
    Address Who gave the history?
    Chief complaint
    The main reason for which the patient is trying to seek
    medical help by visiting the physician.
    Usually a single symptoms, occasionally more than one
    complaints eg: fever, headache, pain, etc
    The patient describe the problem in their own words.
    It should be recorded in patients own words.
    The complain should be recorded with their onset duration
    How to ask for chief complaint?
    What brings your here?
    How can I help you?
    What seems to be the problem?
    If there is more than one complaint, it should be written
    according to chronological order
    Example
    Example,
    Fever-2 weeks,
    Productive cough-1 week,
    Vomiting
     -2 days,
    Fatigue-1day,
    History of the present illness
    Elaborate on the chief complaint in detail
    Ask relevant associated symptoms
    Gain as much information you can about the specific
    complaint.
    Lead the conversation by asking questions.
    Always start with an open ended question and take the time
    to listen to the patient’s ‘story’.
    Once the patient has completed their narrative then closed
    questions can be asked to clarify .
    Leading question are to be avoided.
    Open questions allow patients to express their own thoughts
    and feelings, e.g. 'Is there anything else that you want to
    mention?’
    Closed questions are requests for factual information, e.g.
    'When did this pain start?’
    Leading questions are based on your own assumptions that
    lead the patient to the answer you want to hear.
    In details of present problem with- time of onset/ mode of evolution/
    any investigation ; treatment &outcome/any associated +’ve or -’ve
    symptoms.
    Avoid medical terminology and make use of a descriptive language
    that is familiar to patients
    Sequential presentation
    Always relay story in days before admission
    Narrate in details
    HPI {Tips to gather information }
    Site
    Onset
    Character
    Radiation (of pain or discomfort)
    Alleviating factors
    Timing
    Exacerbating factors
    Severity
    S
    O
    C
    R
    A
    T
    E
    S
    EXAMPLE OF HPI
    The patient was apparently well 1 week before the admission
    when the patient fell while gardening and cut his foot with a
    stone.
    By that evening, the foot became swollen and patient was
    unable to walk. Next day patient attended a private clinic
    where they gave him some oral medicines.
    The patient doesn’t know the name of the medicines given
    but says that he was told the medicine would suppress his leg
    pains .
    however There was no improvement in his condition.
    Two days prior to admission in ward , the swelling in the
    foot started to discharge pus. There is high fever and rigors
    with nausea and vomiting.
    Past medical history
    Any history of similar complaint in the past
    Other medical problems the patient has or had
    Any chronic disease present like hypertension, diabetes etc
    Past hospitalizations and past surgeries
    Medications if any taken in the past (dosage and duration)
    Allergies
     Pediatric: Birth history, Developmental Milestones,
    Immunizations
     Gyane /Obstetric history if female
    Family history
    It is important to establish whether there are any genetically
    transmitted diseases within families
    Any illness run in the family?
    Similar history in the family, Parents and siblings suffering
    with any chronic illness
    Parents if died, how old and what they died of
    You should be able to collect relevant family history
    depending upon the present illness.
    Example, Patient has come due anemia , Try to rule out
    sickle cell, thalassemia / G6PD deficiency
    Socioeconomic history
    Smoking history - amount, duration and type.
    Drinking history - amount, duration and type
    Any drug addiction
    Sexual history if suspected STI
    Occupation, social and education background, financial
    situation
    System Review
    General
    Weakness
    Fatigue
    Anorexia
    Change of weight
    Fever
    Lumps
    Night sweats
    Gastrointestinal/Alimentary
    Appetite (anorexia/weight change)
    Diet
    Nausea/vomiting
    Regurgitation/heart burn/flatulence
    Difficulty in swallowing
    Abdominal pain/distension
    Change of bowel habit
    Haematemesis , melaena
    Jaundice
    Cardiovascular
    Chest pain
    Paroxysmal Nocturnal Dyspnoea
    Orthopnoea
    Short Of Breath
    Cough/sputum
    Palpitations
    Cyanosis
    Respiratory System
    Cough(productive/dry)
    Sputum (colour, amount, smell)
    Haemoptysis
    Chest pain
    SOB/Dyspnoea
    Tachypnea
    Hoarseness
    Wheezing
    System review
    Urinary System
    Frequency
    Dysuria
    Urgency
    Hesitancy
    Terminal dribbling
    Nocturia
    Back/loin pain
    Incontinence
    Character of urine: color/ amount (polyuria) & timing
    Fever
    Genital system
    Pain/ discomfort/ itching
    Discharge
    Unusual bleeding
    Nervous System
    Visual/Smell/Taste/Hearing/
    Speech
    Head ache
    Fits/Faints/Black outs/loss of consciousness(LOC )
    Muscle weakness/ numbness/
    paralysis
    Abnormal sensation
    Change of behavior or psyche
    Musculoskeletal System
    Pain – muscle, bone, joint
    Swelling
    Weakness/movement
    Deformities
    Now you’ve got your information
    Give a Summary
     Ask if you’ve understood the information correctly
    Ask if there is any other information that the patient wants
    you to know
     Advise what your plan would be
    Check with the patient that they are in agreement with your
    plan

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