صفحه 1:
یج
.7
صفحه 2:
1م 1 زنل11 1ل
TAKING
Dr. Mohammad Shaikhani.
Assistant Professor.
3 year practical sessions on
History taking.
Dept of Medicine.
University of Sulaimani.
Modified from an internet presentation by an Iranian author.
صفحه 3:
Session Structure
Introduction and Describing Aim &Objectives PAU Bitty
Chief complaint رسب
—=a pn 1 ا
Past medical history wo (4
Systemic enquiry nc
Family history 85 10min
Drug history ص10
Social history sui ۳
ب نم بح م و نج و
صفحه 4:
Importance of History
Taking
* Obtaining an accurate history is the
critical first step in determining the
etiology of a patient's problem.
* A large percentage of the time ) 70%),
you will actually be able make a
diagnosis based on the history alone.
صفحه 5:
How to take a history?
¢ The sense of what constitutes important data
will grow exponentially in future as you learn
about the pathophysiology of disease
* You are already in possession of the tools
that will enable you to obtain a good history.
COVE Vin mcm ال ال
questions that help define the nature of a
particular problem.
* A vast & sophisticated fund of knowledge not
needed to successfully interview a patient.
صفحه 6:
;eneral Approach
@ Introduce yourself.
* Note - never forget patient names
* Creat patient appropriately in a friendly
۲۵1201 ۰
*Confidentiality and respect patient privacy.
G Try to see things from patient point of view.
Understand patient underneath mental
status, anxiety, irritation or depression.
Always exhibit neutral position.
۳
G Questioning: simple/clear/avoid medical
terms/open, leading, interrupting, direct
questions and summarizing.
صفحه 7:
Taking the history &
۰ Recording:
* Always record personal details: NASEOMADR.
- Name,
- Age,
- Address,
- Sex,
- Ethnicity
- Occupation,
- Religion,
- .ها آهمانیم]
- Date of examination
صفحه 8:
Complete History Taking
Chief complaint
۱۰۱۱۱۱۱ ny
Past medical /surgical history
Systemic review
Family history
Drug /blood transfusion history
Social history
Gyn/ob history.
صفحه 9:
CHIEF COMPLAINT
صفحه 10:
Chief Complaint
KO eke ل ل ل اك لان
visiting a physician or for help
¢ Usually a single symptoms, occasionally
more than one complaints eg: chest pain,
SCV ieyie UAC Mani ا ا ان
swelling etc
¢ The patient describe the problem in their
own words.
¢ It should be recorded in pt’s own words.
* What brings your here? How can I help
you? What seems to be the problem?
صفحه 11:
Chief Complaint
Cheif Complaint (CC):
¢ Short/specific in one clear sentence
communicating present/major
problem/issue. As:
* Timing - fever for last two weeks or since
۱/۸
episode of abdominal ار
pain/cough
¢ Any major disease important e.g. DM,
asthma, HT, pregnancy, IHD:
* Note: CC should be put in patient language.
صفحه 12:
Duration: tips
* Exact duration.
¢ For how long you are ill.
* When you were completely normal.
¢ Is this complain for the first time or you
have other episodes.
صفحه 13:
History of Present
111265
Details & progression, regression of
the CC:
صفحه 14:
History of Present Illness -
۱
* Elaborate on the chief complaint in
detail
¢ Ask relevant associated symptoms
* Have differential diagnosis in mind
* Lead the conversation & thoughts
* Decide & weight the importance of
minor complaints
صفحه 15:
History of Presenting Complaint (HPC)
2 عستا عطغتنة سعاطه:م غمصعوععم 2ه كلتهغأع0 م1 01
onset/ mode of evolution/ any
investigation;treatment &outcome/any
associated +’ve or -’ve symptoms.
3 Sequential presentation
UCR CNM RU MMLC NAM Ty Kt ay
admission e.g. 1 week before the
admission, the patient fell while
gardening& cut his foot with a stone.
*Narrate in details - By that evening, the
foot became swollen and patient was
unable to walk. Next day patient attended
hospital and they gave him some oral
antibiotics. He doesn’t know the name.
There is no effect on his condition and two
davs prior to admission. the foot continued
صفحه 16:
History of Presenting Complaint (HPC)
In details of symptomatic presentation
*If patient has more than one symptom, like chest pain,
swollen legs and vomiting, take each symptom individually
and follow it through fully mentioning significant
negatives as well. E.g the pain was central crushing pain
radiating to left jaw while mowing the lawn. It lasted for
ACEO U TUR e TCA a CAC Mm l ati mac) ame)
صتعم عنطا ل ناش عصمامصوی 0عاونهمکوه
before/no relation with food/he is Known smoker,diabetic
& father died of heart attack at age of 45.
صفحه 17:
History of Present
Illness - Tips
* Avoid medical terminology & make
use of a descriptive language that is
familiar to them
* Ask OPQRSTA for each symptom
صفحه 18:
Pain (OPORST)
Onset of
ات۱
Position/
nature, character - burning sharp, رسناگال
stabbing, crushing; also explain depth of pain -
or other bodily 0 موز
function/position.
Radiation: where moved to
Relieving or ravating factors - a: ctivities or
0 ic 3 اج 0 Baran sical
activities. Wakes him up at night, cannot sleep/do
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progression (continuous or intermittent - if
intermittent ask frequency/ nature.)
Treatment received or/and outcome.
. 53772221:01257 35500131560 تقة عتدعط عتدثم
صفحه 19:
Past Medical Illness
صفحه 20:
دما وز۲]
Start by asking the patient if they have any
medical problems
IHD/Heart Attack/DM/Asthma/HT/RHD,
TB/Jaundice/Fits :E.g. if diabetic- mention time of
diagnosis/current medication/clinic check up
Past surgical/operation history
E.g. time/place/ what type of operation.
Note any blood transfusion / blood grouping.
H/O dental extractions/circumcision & any
exessive bleeding during these procedures.
History of trauma/accidents
E.g. time/place/ and what type of accident
Any minor operations or procedures including
endoscopies, dental interventions, bipsies.
صفحه 21:
Drug History
صفحه 22:
Drug History
* Drug History (DH)
¢ Always use generic name or put trade name in
brackets with dosage, timing &how long.
¢ Example: Ranitidine 150 mg BD PO
* Note: do not forget to mention:
OCT/Vitamins/Traditional /Herbal medicine &
alternative medicine as cupping or cattery or
acupuncture.
* Blod transfusion.
صفحه 23:
Drug History
MGC MC MM Mist نستتتدمحط :13[دناكن) تتلتهل 0
night)
tds (ter die sumendus)/tid (ter in die) = Three
۱9 "اتتتامط 8 تإلستهمد تجهك جه
qds (quarter die sumendus)/qid (quarter in die) =
four times daily mainly 6 hourly
Mane/(om - omni mane) = morning
Nocte/(on - omni nocte) = night
ac (ante cibum) = before food
pc (post cibum) = after food
Me merce ta ty ا
stat - statim = immediately as initial dose
Rx (recipe) = treat with
صفحه 24:
Family History
صفحه 25:
Family History
¢ Any familial disease/running in
families e.g. breast cancer, IHD, DM,
schizophrenia, Developmental delay,
asthma, albinism.
٠ Infections running in families as TB,
Leprosy.
* Cholera, typhoid in case of
epidemics.
صفحه 26:
Social History
صفحه 27:
Social History
Smoking history - amount, duration & type.
A strong risk factor for IHD
Alcohol history - amount, duration & type.
Occupation, social & education background, ADL,
SCVMM CIE yakitori LCT
Social class.
Home conditions as:
Water supply.
Sanitation status in his home & surrounding.
PUL Cw mae تتاعط/عتط صذة 5.
صفحه 28:
Social History: smoking
The most important cause of preventable
diseases.
Smoking history - amount, duration & type.
Amount: pack” year calculations.
Duration: continuous or interrupted.
Any trials of quitting & how many.
Deep inhalation or superficial.
Active or passive smoker.
Type: packs, self-made, Cigars, Shesha ,
chewing etc.
صفحه 29:
Social History: smoking
¢ Ask the smoker whether he is willing to
quit or not.
* Do not forget to encourage the smoker to
quit whenever contacting a smoker as it is
proved to increase quitting rate.
* If he is willing to quit, but can not, help
۱۱۱۱۱۱۰۱۵ لل
صفحه 30:
Social History: alcohol.
Whether drinking alcohol or not.
۸ 0۴ وطااجعظ و1 1 دمطامطاه ا ودناصی 1۶
Healthy alcohol use:
Men: 14 units/week, not > 4 units/session.
Women: 7 units/week, not > 2 units/session.
Don’t forget that healthy alcohol use is
associated with less IHD & Ischemic CVA.
Unhealthy alcohol use is associated with
cardiomyopathy, CVA, Myopathies, liver
cirrhosis & CPNS dysfunction.
صفحه 31:
Social History: alcohol.
* Note: Do not advice patients or
individuals , to drink for health,
because of:
* Religious & cultural reasons.
* Possibility of addiction with its
known health problems.
صفحه 32:
Other Relevant History
* Gyane/Obstetric history if female
* Gravida, para, abortions, SZ sections,
antenatal care & screens as for Hep
B&C.
صفحه 33:
Other Relevant History
Immunization if small child
Note: Look for the child health card.
Travel / sexual history if suspected STDs or
Puan CMI ies
Note:
If small child, obtain the history from the care
giver. Make sure; talk to right care giver.
bam Cee Tae Clea Cette Ce Com
get an interpreter(neutral not family friend or
member also familiar with both language). Ask
simple & straight question but do not go for
yes or no answer.
صفحه 34:
System Review (SR)
عتقتطاتقصة دكتدط 0غ 201 عل0ذنان ج 15 عنط1'
Any significant finding should be moved t¢
HPC or PMH depending upon where you
think it belongs.
1۳0 ۳۵۲ 10۲06۵۲ 10 عاكة 2550121640 5
of PC with the System involved
When giving verbal reports, say no
significant finding on systems review to
show you did it. However when writing up
patient notes, you should record the
ات
doctors know what system you covered.
صفحه 35:
System Review
General
Weakness
*Fatigue
¢ Anorexia
*Change of weight
*Fever/chills
5
*Night sweats
صفحه 36:
System Review
Cardiovascular
Chest pain
*Paroxysmal Nocturnal Dyspnoea
*Orthopnoea
«Short Of Breath(SOB)
*Cough/sputum (pinkish/frank blood)
*Swelling of ankle(SOA)
*Palpitations
*Cyanosis
صفحه 37:
System Review
Gastrointestinal/Alimentary
Appetite (anorexia/weight change)
۲
1
*Regurgitation/heart burn/flatulence
* Difficulty in swallowing
طمتعصماونل/صنع انوم ۸
*Change of bowel habit
*Haematemesis, melaena,
haematochagia
*Jaundice
صفحه 38:
System Review
Respiratory System
*Cough(productive/dry)
*Sputum (colour, amount, smell)
*Haemoptysis
*Chest pain
*SOB/Dyspnoea
*Tachypnoea
*Hoarseness
*Wheezing
صفحه 39:
System Review
Urinary System
Frequency
11101112
*Urgency/strangury
*Hesitancy
*Terminal dribbling
*Nocturia
*Back/loin pain
*Incontinence
*Character of urine:color/ amount
عسنستا ع (همتسسسوامم)
°Fever
صفحه 40:
System Review
Nervous System
*Visual/Smell/Taste/Hearing/Speech
۱۱۱۱: ابیت
*Head ache
*Fits/Faints/Black outs/loss of
consciousness(LOC)
*Muscle weakness/numbness/paralysis
*Abnormal sensation
basing
*Change of behaviour or psyche.
*Pariesis.
صفحه 41:
System Review
Genital system
*Pain/ discomfort/ itching
*Discharge
Unusual bleeding
*Sexual history
*Menstrual history - menarche/ LMP/
duration & amount of cycle/
Contraception
*Obstetric history - Para/
ل الاك
صفحه 42:
System Review
Musculoskeletal System
*Pain - muscle, bone, joint
تاه
*Weakness/movement
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6
صفحه 43:
SOAP
© Subjective: how patient feels/thinks about
him. How does he look. Includes PC and
general appearance/condition of patient
©@ Objective - relevant points of patient
complaints/vital sings, physical
examination/daily weight, fluid
00 1 ل
after‘ making a problem list. Make
111167 ناه ۰
© Plan - about management, treatment,
further investigation, follow up and
rehabilitation