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HISTORY TAKING FROM A PATIENT. M K Alam MS,FRCS Professor of Surgery. PATIENT’S PROBLEM. HOW TO SOLVE IT? HISTORY CLINICAL EXAMINATION CLINICAL DIAGNOSIS INVESTIGATIONS FINAL DIAGNOSIS TREATMENT. IMPORTANT POINTS BEFORE HISTORY-TAKING. - PowerPoint PPT Presentation
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M K Alam MS,FRCSProfessor of Surgery
PATIENT’S PROBLEM HOW TO SOLVE IT?
HISTORYCLINICAL EXAMINATIONCLINICAL DIAGNOSISINVESTIGATIONSFINAL DIAGNOSISTREATMENT
IMPORTANT POINTS BEFORE HISTORY-TAKINGIntroduce yourselfExplain yourselfFull attentionTreat with respectLet patient talkGuide, not dictateNo leading questionNo short-cutsTry not to write and talk to the patient at the
same time
Different parts of a historyPERSONAL DETAILSPRESENTING COMPLAINTHISTORY OF PRESENT ILLNESSSYSTEMIC INQUIRYPAST MEDICAL/SURGICAL HISTORYFAMILY HISTORYHISTORY OF MEDICATIONSSOCIAL HISTORYOTHER HISTORY
PERSONAL DETAILSNAMEAGESEXNATIONALITYMARITAL STATUSOCCUPATION Record date of history taking and
examination
PRESENTING COMPLAINT
What are you complaining of? (record in patient’s own words)
When more than one complain: (record in order of severity)
HISTORY OF PRESENT ILLNESSFull details of the complaint or complaints.Get right back to the beginning of the trouble.Each complain- fully analyzed e.g., pain
Site Time and mode of onset ( sudden, gradual) Severity Nature (aching, burning, stabbing, constricting, throbbing) Progression Duration Aggravating/ relieving factors Radiation Cause
SYSTEMIC INQUIRY of the involved or affected system
Example:
Chief complaint related to gastrointestinal system(GI)-
continue with the GIT inquiry.
SYSTEMIC INQUIRY GASTRINTESTINAL SYSTEM
WeightAppetiteDysphagiaNauseaVomitingHeartburnHaematemesisFlatulence
JaundiceAbdominal painFat intoleranceConstipationDiarrhoeaMelaenaRectal bleedingStool
SYSTEMIC INQUIRY RESPIRATORY SYSTEM
CoughSputumHemoptysisWheezeDyspnoeaChest painSmoking
SYSTEMIC INQUIRY UROGENITAL SYSTEM
Loin painDysuriaNocturiaFrequencyHaematuriaUrinary streamIncontinenceUrethral discharge
SYSTEMIC INQUIRY CARDIOVASCULAR SYSTEM
Angina (cardiac pain)Dyspnoea ( rest/ exercise)PalpitationsAnkle swellingClaudicationVaricose veins
SYSTEMIC INQUIRY
Obstetric & Gynecology
LMPVaginal dischargeVaginal bleedingPregnancies
Nervous system
Headache FitsDepressionFacial/limb
weakness
SYSTEMIC INQUIRY MUSCULOSKELETAL
Muscular painBone & Joint painSwelling of jointsLimitation of movementsWeakness
SYSTEMIC INQUIRY METABOLIC/ENDOCRINE
Bruising/ bleedingSweatingThirstPruritusAlcoholWeight
PAST MEDICAL/SURGICAL HISTORY
Rheumatic FeverTuberculosis/ AsthmaDiabetesJaundice Operations/ AccidentBlood transfusionMental illness
FAMILY HISTORY
DiabetesHypertensionHeart diseaseMalignancyCause of death
Father/Mother/Siblings/Spouse/Children/Close relatives
HISTORY OF MEDICATIONS
InsulinSteroidsNSAIDContraceptive pillsAntibioticsOthers
SOCIAL HISTORYMarital statusOccupationTravel abroadAccommodationHabits ( smoking, alcohol )Dependent relatives
OTHER HISTORYPsychiatric/ Emotional background
Allergies Food Drugs
Immunizations Tetanus Diphtheria Tuberculosis Hepatitis Others
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