HISTORY TAKING
اسلاید 1: www.tabaye.ir
اسلاید 2: HISTORY TAKINGDr. Mohammad Shaikhani.Assistant Professor.3rd year practical sessions on History taking.Dept of Medicine.University of Sulaimani.Modified from an internet presentation by an Iranian author.
اسلاید 3: Session StructureIntroduction and Describing Aim &Objectives 20 minChief complaint 10minHistory of present illness 10minPast medical history 10minSystemic enquiry 10minFamily history 10minDrug history 10minSocial history 10min Pair Group and Role Play
اسلاید 4: Importance of History TakingObtaining an accurate history is the critical first step in determining the etiology of a patients problem.A large percentage of the time ) 70%), you will actually be able make a diagnosis based on the history alone.
اسلاید 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 diseaseYou are already in possession of the tools that will enable you to obtain a good history. An ability to listen &ask common-sense questions that help define the nature of a particular problem. A vast & sophisticated fund of knowledge not needed to successfully interview a patient.
اسلاید 6: Introduce yourself. Note – never forget patient names Creat patient appropriately in a friendly relaxed way.Confidentiality and respect patient privacy.General Approach Try to see things from patient point of view. Understand patient underneath mental status, anxiety, irritation or depression. Always exhibit neutral position.ListeningQuestioning: simple/clear/avoid medical terms/open, leading, interrupting, direct questions and summarizing.
اسلاید 7: .Taking the history & Recording: Always record personal details: NASEOMADR.Name,Age,Address,Sex,EthnicityOccupation,Religion,Marital status. Date of examination
اسلاید 8: Complete History TakingChief complaintHistory of present illnessPast medical /surgical historySystemic reviewFamily historyDrug /blood transfusion historySocial historyGyn/ob history.
اسلاید 9: CHIEF COMPLAINT
اسلاید 10: Chief ComplaintThe main reason push the pt. to seek for visiting a physician or for helpUsually a single symptoms, occasionally more than one complaints eg: chest pain, palpitation, shortness of breath, ankle swelling etcThe 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?
اسلاید 11: Chief ComplaintCheif Complaint (CC):Short/specific in one clear sentence communicating present/major problem/issue. As: Timing – fever for last two weeks or since MondayRecurrent –recurring episode of abdominal pain/coughAny major disease important e.g. DM, asthma, HT, pregnancy, IHD: Note: CC should be put in patient language.
اسلاید 12: Duration: tipsExact duration.For how long you are ill.When you were completely normal.Is this complain for the first time or you have other episodes.
اسلاید 13: History of Present IllnessDetails & progression, regression of the CC:
اسلاید 14: History of Present Illness - TipsElaborate on the chief complaint in detailAsk relevant associated symptomsHave differential diagnosis in mindLead the conversation & thoughtsDecide & weight the importance of minor complaints
اسلاید 15: Sequential presentation Always relay story in days before 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 days prior to admission, the foot continued to swell and started to discharge pus. There is high fever and rigors with nausea and vomiting.History of Presenting Complaint (HPC)In details of present problem with- time of onset/ mode of evolution/ any investigation;treatment &outcome/any associated +’ve or -’ve symptoms.
اسلاید 16: History of Presenting Complaint (HPC)In details of symptomatic presentationIf 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 less than 5 minutes and was relieved by taking rest. No associated symptoms with pain/never had this pain before/no relation with food/he is Known smoker,diabetic & father died of heart attack at age of 45.
اسلاید 17: History of Present Illness - TipsAvoid medical terminology & make use of a descriptive language that is familiar to them Ask OPQRSTA for each symptom
اسلاید 18: Pain (OPQRST)Position/siteSeverity – how it affects daily work/physical activities. Wakes him up at night, cannot sleep/do any work.Relationship to anything or other bodily function/position. Radiation: where moved toRelieving or aggravating factors – any activities or positionQuality, nature, character – burning sharp, stabbing, crushing; also explain depth of pain – superficial or deep.Timing – mode of onset (abrupt or gradual), progression (continuous or intermittent – if intermittent ask frequency/ nature.)Treatment received or/and outcome. Onset of disease Are there any associated symptoms? .
اسلاید 19: Past Medical Illness
اسلاید 20: Past Medical /Surgical HistoryStart 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 upPast surgical/operation historyE.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/accidentsE.g. time/place/ and what type of accidentAny minor operations or procedures including endoscopies, dental interventions, bipsies.
اسلاید 21: Drug History
اسلاید 22: Drug HistoryDrug 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.
اسلاید 23: Drug Historybd (Bis die) - Twice daily (usually morning and night)tds (ter die sumendus)/tid (ter in die) = Three times a day mainly 8 hourlyqds (quarter die sumendus)/qid (quarter in die) = four times daily mainly 6 hourlyMane/(om – omni mane) = morningNocte/(on – omni nocte) = nightac (ante cibum) = before foodpc (post cibum) = after foodpo (per orum/os) = by mouthstat – statim = immediately as initial doseRx (recipe) = treat with
اسلاید 24: Family History
اسلاید 25: Family HistoryAny familial disease/running in families e.g. breast cancer, IHD, DM, schizophrenia, Developmental delay, asthma, albinism.Infections running in families as TB, Leprosy.Cholera, typhoid in case of epidemics.
اسلاید 26: Social History
اسلاید 27: Social HistorySmoking history - amount, duration & type. A strong risk factor for IHDAlcohol history - amount, duration & type. Occupation, social & education background, ADL, family social support& financial situation.Social class.Home conditions as:Water supply.Sanitation status in his home & surrounding.Animals / birds in his/her house.
اسلاید 28: Social History: smokingThe 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.
اسلاید 29: Social History: smokingAsk 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 him by NRT, buberpion.
اسلاید 30: Social History: alcohol.Whether drinking alcohol or not.If drinking know whether it is healthy or not.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.
اسلاید 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.
اسلاید 32: Other Relevant History Gyane/Obstetric history if femaleGravida, para, abortions, SZ sections, antenatal care & screens as for Hep B & C.
اسلاید 33: Other Relevant History Immunization if small childNote: Look for the child health card.Travel / sexual history if suspected STDs or infectious diseaseNote:If small child, obtain the history from the care giver. Make sure; talk to right care giver.If some one does not talk to your language, 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.
اسلاید 34: System Review (SR)This is a guide not to miss anythingAny significant finding should be moved to HPC or PMH depending upon where you think it belongs.Do not forget to ask associated symptoms of PC with the System involvedWhen 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 systems review so that the relieving doctors know what system you covered.
اسلاید 35: System ReviewGeneral WeaknessFatigueAnorexiaChange of weightFever/chillsLumpsNight sweats
اسلاید 36: System ReviewCardiovascularChest painParoxysmal Nocturnal DyspnoeaOrthopnoeaShort Of Breath(SOB)Cough/sputum (pinkish/frank blood)Swelling of ankle(SOA)PalpitationsCyanosis
اسلاید 37: System ReviewGastrointestinal/Alimentary Appetite (anorexia/weight change)DietNausea/vomitingRegurgitation/heart burn/flatulenceDifficulty in swallowingAbdominal pain/distensionChange of bowel habitHaematemesis, melaena, haematochagiaJaundice
اسلاید 38: System ReviewRespiratory SystemCough(productive/dry)Sputum (colour, amount, smell)HaemoptysisChest pain SOB/DyspnoeaTachypnoeaHoarsenessWheezing
اسلاید 39: System Review Urinary SystemFrequencyDysuriaUrgency/stranguryHesitancy Terminal dribblingNocturiaBack/loin painIncontinenceCharacter of urine:color/ amount (polyuria) & timingFever
اسلاید 40: System Review Nervous SystemVisual/Smell/Taste/Hearing/Speech problemHead acheFits/Faints/Black outs/loss of consciousness(LOC)Muscle weakness/numbness/paralysisAbnormal sensationTremorChange of behaviour or psyche.Pariesis.
اسلاید 41: System Review Genital system Pain/ discomfort/ itchingDischargeUnusual bleedingSexual historyMenstrual history – menarche/ LMP/ duration & amount of cycle/ ContraceptionObstetric history – Para/ gravida/abortion
اسلاید 42: System Review Musculoskeletal SystemPain – muscle, bone, jointSwellingWeakness/movementDeformitiesGait
اسلاید 43: SOAPSubjective: how patient feels/thinks about him. How does he look. Includes PC and general appearance/condition of patientObjective – relevant points of patient complaints/vital sings, physical examination/daily weight,fluid balance,diet/laboratory investigation and interpretationPlan – about management, treatment, further investigation, follow up and rehabilitationAssessment – address each active problem after making a problem list. Make differential diagnosis.
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