Question

Procedure 3 : Patient history taking

Answer 1

PATIENT HISTORY TAKING

MEANING

It is a process by which the information is gained by a phisician by asking specific questions to th patient with the aim of obtaining information useful in formulating a diagnosis and providing medical care to the patient.

COMPONENTS OF HISTORY TAKING

1. ​​​​​​​PATIENT PROFILE
2. CHIEF COMPLAINTS
3. HISTORY OF THE PRESENT ILLNESS
4. PAST MEDICAL HISTORY
5. PRESENT SURGICAL HISTORY
6. PAST SURGICAL HISTORY
7. FAMILY HISTORY
8. SOCIO ECONOMIC HISTORY
9. SYSTEM REVIEW

PATIENT PROFILE

Date and Time

Name

Age

Sex

IP number

Religion

MArital Status

Occupation

Address

Who gave the history

CHIEF COMPLAINTS

• The main reason for which the patient is trying to seek the medical help.
• .It may includes single symptoms or more than one complaints.Eg: Fever,Headache,body pain etc
• The patient will describe the problems in his/her own words.
• These complaints should be recorded with their onset duration. Eg:Cough since 5 days,Vomiting since 2 days

HISTORY OF PRESENT ILLNESS

• Elaborate the chief complaints in detail
• Ask relevant associated problems
• Gain as much informations about the problem
• Avoid using medical terminologies while asking the questions

PAST MEDICAL HISTORY

• It includes the history of similar complaints in the past
• Any diseases is present like hypertension,diabetes mellitus etc
• Past hospitalisation or medications taken (if yes, ask the dossage and duration)
• allergies towards any medications
• If the patient is paediatric - Birth history, Developmental Milestones and Immunizations
• Gyane/Obstetric history in female.

PRESENT SURGICAL HISTORY

It include the surgery which has been done for the present illness.(If yes,which surgery,time ,date,doctor's name and any surgical complications are present or not)

PAST SURGICAL HISTORY

It includes the history of previous surgeries done for the patient for this same disease of any other disease.(If yes, what surgery,date of surgery, any surgicals complications founded.)

FAMILY HISTORY

• It includes the information regarding any genetically transmitted diseases within the family.
• Any illness run in the family
• Similar history in the family
• Parents and sibbling are suffering with any chronic diseases.
• If the parents died,how old and what they died of.

SOCIO-ECONOMIC HISTORY

• It includes who is the head of the family and what is the financial background of the family
• What is the education and occupation of the patient
• Home condition and water supply
• Sanitation status in the home and surroundings
• Any drug Addition
• Smoking history - amount,duration and type
• Drinking history - amount,duration and type

SYSTEM REVIEW/PHYSICAL EXAMINATION

General

• ​​​​​​​​​​​​​​​​​​​​​Weakness
• Fatigue
• Anorexia
• Change of weight
• Fever
• Lumps
• Night Sweats

Gastrointestinal/Alimentary tract

• Appetite
• Diet
• Nausea/vomiting
• Regurgitation/heart Burn/Flatulence
• Abdominal pain/Distension
• Change of bowel habits
• Haematemesis/melaena
• Jaundice

Cardiovascular

• Chest pain
• Paroxysmal Nocturnal Dyspnoea
• Orthopnoea
• Short of Breath
• Cough/sputum(pinkish/frank blood)
• Palpation
• Cynosis

Respiratory System

• Cough(productive or dry)
• Sputum(color,amount,smell)
• Haemoptysis
• Chest pain
• Dyspnoea
• Tachypnoea
• Hoarseness
• Wheezing

Urinary System

• Freequency
• Dysuria
• Urgecy
• Hesitancy
• Terminal dribbling
• Nacturia
• Back painIncontinence
• Character of urin color/odour/amount/timing

Genital System

Female

• Pain/Dyscomfort/itchng
• Discharge
• unusual bleeding
• Sexual history
• Menstural history - menarche/LMP/duration and amunt of cycle
• Usage of contraceptives
• Obstetric history - Para/gravida/abortion

Male

• Hydrocele
• Hernia or tumour of testis
• Inflamation of the prostate Glands

Nervous System

• Impairement in vision,smell,taste,hearing and speech
• Headache
• Fits/faints/blackout/loss of consciousness
• paralysis
• Abnormal sensation
• Sudden changes in behaviour

Musculoskeletal System

• Pain - muscle,bone,joints Etc.
• Swelling
• Weakness/inability to move
• Deformities