History taking

1. History taking
By Dr/
Muhamad Fathy Zydan (MD)

2. • Personal H, including menstrual H in females
• Presenting complaint
• History of the present illness
• Past H of illness
• Treatment H
• Family H

3. Personal History
• Name
• Age
• Sex
• Residence
• Occupation
• Marital status
• Menstrual H
• Special habits

4. Personal History
• A male patient called Muhamad Ali, 68 years
old, born and raises in El-Fayoum Egypt,
Driver, Married 41 years ago and has 4 (
children's , offspring's ) the (last one ,
youngest) is 22 years old, he smokes 50
cigarettes per day for 48 years.

5. Age related diseases

6. Age related I.O
• D1= (Atresia- Malrotation- HSD- Meconium
ileus- congenital web or Bands – hernias-
imperforate anus)
• 5-6 weeks = CHPS
• 6-12 months = Intuss
• Adult (hernias- masses – adhesions-
inflamatory process …)
• Old age (Malignancy- adhesive-inflammatory
process -volvulus – ..)

7. Sex related D.

8. Residence and Race related D

9. Occupation
• Sun exposure
• Drivers
• Sport
• Chemicals
• Long standing
• Weightlifting
• Work related Bursa

10. Occupation

11. Marital state
• Fertility and No. of children's
• Include the menstrual and obstetrical H at this
point
• Breast feeding
• Methods of contraception
• Sexual transmitted diseases

12. Menstrual and obstetric history
• Age of menarche
• Duration of the menses, Regular or not ,and
kind of irregularity and for how long
• No. of pregnancies
• First full term pregnancy
• Date of the last menst. Cycle
• Age of menopause
• Bleeding after menopause

14. Special habits
• Smoking related cancers and other diseases
• Alcohol related diseases
• Injections related diseases

15. Complaint

16. Complaint
• What are you complaining of ?
• What is the matter ?
• One complain better
• The most disturbing one if many
• By the patient’s own words
• No medical terms ( yellow discoloration of the
sclera not jaundice )

17. Complaint
• PAIN
• lump
• Bleeding
• Disfigurement
• GIT (N ,V, CONST., D., DISTENTION, …..)
• OTHER SYS . ??

18. PRESENT HISTORY
• A-Analysis of the complaint
• B-Symptoms of the related system
• C-Symptoms of the other systems

19. Present history
A-Analysis of the complaint
1-OCD (Onset- Course –Duration )
2-Detailed history about the complaint

20. 1-OCD
Ask the patient about the
last time he was quite well
and from that you can
record the duration of his
illness

21. OCD
mode of ONSET
• Instantaneous or sudden , when the
symptoms develops and reaches its
maximum in just few seconds or minutes
• Acute , symptoms develops over hours or
days
• Gradual, takes several weeks to develops
• Accidentally discovered , by the patient
or his doctor during routine check up

22. Onset

23. OCD
the course
• Progressive
• Regressive
• Stationery
• Remittent (not returning to the normal
state)
• Intermittent ( with intervening periods of
feeling normal)

24. Analysis of the complaint
2-Detailed history about the complaint
EXAMPLE 1
COMPLAINT = PAIN
1-OCD
2-Site (localized or diffused)
3-Radiation or if referred to any site
4-Character
5-Sevirity ( how it affects the patient life )
6-Relation to trauma
7-What aggravates it
8-What relives it
9-Associated symptoms

25. Pain as a complaint
Breast pain (Mastalgia)
• OCD (PAIN started 2 days ago with sudden onset and rapidly
progressive course )
• Started at the nipple after an abrasion by her nursing baby teeth
• Hours later referred to upper lateral sector of the breast and the
homolateral axilla
• The pain started mild and sharp , day later become sever and
throbbing
• At first it decreased by elevation and mild analgesic , later no
analgesics affecting its severity
• Increased by breast feeding
• Associated first by abrasion on the nipple , later by redness and
swilling at the upper lateral segment of the breast

26. Pain as a complaint
UNILATERAL LOWER LIMB PAIN
• OCD (PAIN started 8 hours ago with sudden onset and
rapidly progressive course )
• Started at the mid thigh level ( left side) and extended
distally to the tips of toes
• The pain very sharp and sever
• Aggravated by motion and slightly decreased by
dependency
• Not affected by analgesic
• Associated by sense of coldness in the same limb and
change in color
• Associated by numbness and motor weakness

27. Detailed history about the complaint
EXAMPLE 2
COMPLAINT = lump
1-OCD
2-Site
3-Relation to ( pain – trauma – constitutional manifestation)
4-Possible cause
5-Special character
6-Effect of swelling on body function (movement, respiration
swallowing …)
7-Dose it ever disappears
8-Other swelling on the body

28. Swelling as a complaint
Breast mass
• OCD (Swelling accidentally discovered on the
left breast 2 weeks ago with slight progression
on its size)
• Painless
• No relation to trauma
• No other swelling on the other breast ,
homolateral or contralateral axilla

29. Swelling as a complaint
Neck mass
• OCD (Swelling appears in front of the neck 12
years ago with slight progressive course during
the 1st 11 years then rapidly increase in size
during the last 6 months)
• Painless
• No relation to trauma
• No other swelling on the neck.
• No special character

30. Present history
B-Symptomes of the related system
Example 1 ( complaint abdominal pain )
1. Taste
2. Dysphagia
3. Hematemesis, vomiting , heart burn, eructation
4. Melena, fresh bleeding per rectum, defecation,
distention
5. Fatty dyspepsia
6. Liver cell failure manifestation

31. Analyze any positive symptom
• Example 1 (Nausea)
1. Is it related to food
2. Whether accompanied by vomiting
3. Is the patient taking any medicine
• Example 2 (Vomiting)
1. Frequency
2. Preceded by nausea or not
3. Relation to meals
4. Relation to pain
5. Quantity and nature of the vomitus and its color
6. Associated pain ,tinnitus or diarrhea

32. • Example 3 (constipation)
1. What is the usual patient habit?
2. Duration
3. Partial or complete
4. Any alternating diarrhea
5. Constipating drugs (e.g. codeine)
6. In infants ask about
• Passage of meconium
• Uses of enemas and laxatives
• Any alternating periods of normal defecation
• Psychic trauma
• Abuse

33. • Example 4 (Bleeding per rectum )
1. OCD
2. Frequency
3. Color
4. Amount
5. Relation to defecation
6. Associated pain and its relation to defication
7. The passage of mucus
8. Bleeding from other orifices
9. Bluish spots on the skin
10. Manifestation of chronic blood loss

34. Present history
C-Symptomes of the other system (review
of body systems )
Again
Analyze any positive symptom
E.g.(cough)
1. Frequency
2. Dry or productive
3. Painful or not
4. Relation to posture
5. What worsen it and what relive

35. Past history
• Any previous illness should be inquired.
• They should be recorded in chronological sequence
with the date of their occurrence and duration.
• Similar attacks.
• Medications and surgical operation.
• Ask about common diseases …DM , HTN , Heart
diseases
• History of previous admission to hospitals and mention
the cause and history of blood transfusion if present.

36. Treatment history
• Details of drugs taken.
1. Type
2. Indication
3. Duse and duration
4. Possible adverse reaction and hypersensitivity.
• Surgery
1. Its time
2. Type of operation and its indication
3. Surgeon and hospital
4. Type of anaesthesia
5. Duration of hospital stay
6. Possible complication and outcome
• Radiotherapy
• psychotherapy

37. Family history
• Enquire about the health and age of the patients parents,
grandparents, brothers, sisters, and children
• If not alive enquire about the cause of death
• If the patient is a child you need the following information
1. The mothers pregnancy
2. Did she take any drugs during pregnancy
3. Birth weight
4. Any difficulties during delivery
5. Mental and physical development in early life
• Enquire about important diseases which have known to
have occurred in the patients immediate relatives

38. Thank you