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History Taking

  1. 1.
  2. 2. The medical student analyses the details and prepares a summary<br />The narration is split down into several steps<br />It is then written down as a summary case sheet <br />
  3. 3. Example: Diagnosis of migraine is made from history alone<br />Otherwise history is supplemented by clinical examination<br />You may also need investigations to confirm the diagnosis<br />
  4. 4. Arriving at a diagnosis helps us in under standing the disease<br />It helps in planning for necessary investigations <br />Treating the disease for a possible cure or if not relief from symptoms <br />
  5. 5. In taking a long cases as much as 10-20 minutes may be allotted <br />Where as in a short case little or no history is taken<br />In cases of medical emergencies you may not have time for history <br />
  6. 6. Say “Hello” or “Good morning” or “Namaskaram”<br />Also one must ask for permission for the interview<br />What matters most is the rapport built up<br />
  7. 7. You are from Parasalla, I am from idichakkaplamoodu<br />Your father was an Abkari contractor, my father is in Excise <br />You are working in IBM, I am interested in computers<br />
  8. 8. The patient himself is the best person to describe his illness <br />The sequence of events are best described by the patient<br />Only the patient can describe the severity of symptoms<br />
  9. 9. How can a relative or a visiting bystander tell the details<br />How can they express the severity of the symptoms<br />Unfortunately in our state the relatives interfere too much <br />
  10. 10. For example the patient is comatose or aphasic<br />The patient is in a seriously ill or terminally ill state<br />The patient is undergoing a procedure or surgery <br />
  11. 11. Patient sitting opposite to or by the side of the examiner<br />The patient may be lying down in the bed, unable to sit up<br />Then one must stand or sit on the right hand side<br />
  12. 12. If so the patient is likely to be disinterested in the interviewer.<br />Instead use small spiral notepads available every where<br />This is just to note down the points not every thing patient says<br />
  13. 13. Then the patient is likely to be disinterested<br />Don’t write down every word the patient says<br />Note down only thing you are likely to forget<br />
  14. 14. Legible<br />Full text <br />Full sentences<br />All headings<br />No scribbling<br />Underlining<br />Coloring<br />
  15. 15. Hence full name of the patient with initials is required<br />Include Mr or Dr or Professor as the case may be<br />Always address the patient by name if possible<br />
  16. 16. Congenital heart diseases in childhood<br />Diphtheria and measles occur in children<br />Heart attack in middle age or old age, but with exceptions<br />
  17. 17. Certain disease occur exclusively in males<br />Certain disease occur exclusively in females<br />Otherwise diseases in general equally affect males and females<br />
  18. 18. Record the exact nature of the work of the patient<br />Not the official nature like ‘manual laborer’ <br />Also try to identify various risk factors & toxin exposures<br />
  19. 19. The complete postal address of the patient is written down<br />The address shall include the name of Post Office and PIN number<br />The name of the next of kin is also needed, in case of death etc<br />
  20. 20. Filariasis is very common in patients residing in costal areas <br />Multiple sclerosis is common in temperate climates<br />It is rare in tropical climates like India<br />
  21. 21. The Inpatient number, number of the bed, ward, number of the unit<br />The date of admission, the date of Surgeries<br />Date of examination of the patient shall be mentioned separately<br />
  22. 22. Fever, cough, sputum, dyspnoea -4 days duration<br />Abdominal pain, nausea and vomiting – 3 days<br />Symptoms that developing later are not routinely included <br />
  23. 23. Along with the onset, nature, progression, offset<br />Associated symptoms, are mentioned separately<br />These may directly indicate the probable diagnosis.<br />
  24. 24. They should not include any details of the history <br />But only the symptoms and duration of each symptom against it<br />Fever – 3 days, Cough – 2 days, Hemoptysis – 1 day<br />
  25. 25. Use phrases when required, to describe the symptoms well<br />For example inability to speak in full sentences<br />Weakness of the right upper and lower limbs, Incontinence of urine <br />
  26. 26. This requires great skill as well as patience from part of the student<br />So one has to be a good listener first of all<br />Only then you can become a good story teller<br />
  27. 27. Then the patient is asked to narrate all the details of symptoms<br />Just prompt them when ever necessary<br />Redirect them is they are going off the track <br />
  28. 28. Patient listening will help the patient in remembering all the symptoms<br />If you interrupt frquently the patient will be diverted<br />The they may not mention important symptoms<br />
  29. 29. If you ask for radiation of chest pain to the left forearm, answer will be yes<br />Always ask open ended questions like is there any radiation?<br />This elicits a true answer more often than otherwise<br />
  30. 30. For example details regarding the sputum color<br />Ask for the frequency of sputum production<br />Ask for the quantity, color, appearance, foul smell, or blood <br />
  31. 31. This includes enquiry into the various cardinal symptoms<br />These are the important symptoms affecting a particular system<br />Making sure that there are no symptoms pertaining to the system<br />
  32. 32. Any history of similar illness in the past; if so the details<br />Diseases which required prolonged bed rest or hospitalization<br />Any of the other important diseases in the past like DM2 HTN CAD PTB<br />
  33. 33. Whether patient is a vegetarian or non vegetarian<br />Is there constipation or frequent stools, retention or incontinence<br />Is there Insomnia or, disturbed sleep, bad dreams early awakening<br />
  34. 34. Smoking habits, it’s age of onset, smoking index, chain smoking<br />Alcoholism since how long and are there intoxications or withdrawals<br />Is there any other addictions like ganja and other drugs<br />
  35. 35. Any similar illnesses in the other members of the family<br />Diseases which required prolonged bed rest or hospitalization<br />Any of the other important diseases in other members DM2 HTN CAD<br />
  36. 36. Thank You<br />