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History Taking
History Taking
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His | history module | 002

  1. 1. TIPS ON HISTORY TAKING Prof. Dr. Aswinikumar Surendran. MD Professor of Medicine, MCH TrivandrumModule No: 2
  2. 2. HISTORY TAKING Story of the illness as narrated by the patient Student or doctor elicits all the details Then writes down in a specific format What is meant by history taking?
  3. 3. HISTORY It gives you a diagnosis in >70% of cases Then investigate to confirm and localise Then treat for a cure/symptom relief Why is history taking very important?
  4. 4. DIAGNOSIS FROM HISTORY Migraine, an important cause of headache Diagnosis arrived at from history alone No investigations needed - simply treat Give an example?
  5. 5. DIAGNOSIS Dia= Disease Gnosis = Knowledge Diagnosis = Knowledge about the disease What is meant by “diagnosis”?
  6. 6. HISTORY TAKING 10-15' in a long case in examination 5-10' in the outpatient department <5' in an emergency department How much time to allot for history taking?
  7. 7. GREET THE PATIENT Say “Hello” or “ Good Morning” Introduce yourself as a medical student Get permission for interview/examination First of all
  8. 8. BUILD UP A RAPPORT Common place of residence Common nature of job of relatives Common area of interest like computers Find some way
  9. 9. TALK TO THE PATIENT DIRECT Patient - best person to describe his illness Only he can, describe sequence of events And tell the severity and important ones Not to the relative or bystander
  10. 10. NEED NOT TALK TO BYSTANDERS Project their own ideas about the case Give importance to details of their choice Even interfere in interview /examination May be unrelated/uneducated/employed
  11. 11. POSITION PATIENT CORRECTLY Patient lying comfortably Yourself standing on right side Throughout the period of interview Make yourself comfortable
  12. 12. NO NOTE-TAKING DURING HISTORY Gets disinterested; even walk away Instead use only small spiral books Just note down forgettable things Not in large note books in any case
  13. 13. CASE SHEET Sit at some other place Write legibly and beautifully To read, understand and refer later Better written later
  14. 14. HOW TO TAKE HISTORY Name, age, sex Residence, occupation, nature of work IP number, Date of admission First collect the patient details
  15. 15. PRESENTING COMPLAINTS Major complaints of the patient For which he has approached doctor Or admitted to the hospital this time What is meant by presenting complaints?
  16. 16. PRESENTING COMPLAINTS To note key problems of the patient In one look at the case sheet In chronological order What is the purpose?
  17. 17. PRESENTING COMPLAINTS Fever, cough, hemoptysis Abd pain, vomiting, loose stools Weakness of upper and lower limbs Only words or phrases
  18. 18. PRESENTING COMPLAINTS Fever – 4 days Cough – 3 days Hemoptysis – 1 day Put in a chronological order
  19. 19. HISTORY OF PRESENT ILLNESS Whole story as narrated by patient So be a “good listener” to the story Later become a good “story teller” Not the “h/o presenting complaints”
  20. 20. TAKE HISTORY IN 3 PHASES First phase: Only narration by patient 2nd phase: Prompt to detail & expand 3rd phase: Make a systematic enquiry Listen, prompt, enquire
  21. 21. FIRST PHASE When did the first symptom start Ask to tell the whole story till to date Do not interrupt, allow him to finish Last time apparently normal
  22. 22. SECOND PHASE Fever – ask for details of fever Cough – ask to detail sputum Hempoptysis – Assess the quantity Find out details of each
  23. 23. THIRD PHASE Ask for cardinal symptoms Select a list from each system Find out each system is affected/not Systematic enquiry
  24. 24. SYSTEMATIC ENQUIRY CVS: Chest pain, dyspnoea, palpitation, syncope RS: Chest pain, cough, dyspnoea, hemoptysis GIT: Vomiting, loose stools, abdominal pain System wise
  25. 25. SYSTEMATIC ENQUIRY CNS: Headache, weakness, numbness, ataxia MSS: Muscle pain, arthralgia, neuralgia HES: Pallor, fatigue, bleedingtendencies System wise
  26. 26. INVESTIGATION DETAILS Details of all investigations Done elsewhere in other clinics Done after admission to this hospital Make a detailed enquiry
  27. 27. TREATMENT DETAILS Ask for all treatment received Both in outside hospitals and inside Tolerance to drugs and side effects Make a detailed enquiry
  28. 28. H/O PAST ILLNESSES Any similar illnesses in the past Illnesses requiring prolonged rest List: DM2/HTN/CAD/PTB/IH All illnesses in past
  29. 29. PERSONAL HISTORY Appetite, loss or gain in weight Veg/non-veg, food for the day Bladder/bowel/sexual habits Regarding habits/what change occurred?
  30. 30. FAMILY HISTORY Father/mother/brothers/sisters Wife and children Similar 3 step approach All illnesses in members of family
  31. 31. SUMMARY OF NATURAL HISTORY How the illness started? How it progressed then? What is the state now? Put it in a nutshell
  32. 32. DIAGNOSTIC POSSIBILITIES Give 4-5 broad diagnosis? Give points in favour of diagnosis? Give points against diagnosis? From history alone

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