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HISTORY TAKING FROM A PATIENT

HISTORY TAKING FROM A PATIENT. M K Alam MS,FRCS Professor of Surgery. PATIENT’S PROBLEM. HOW TO SOLVE IT? HISTORY CLINICAL EXAMINATION CLINICAL DIAGNOSIS INVESTIGATIONS FINAL DIAGNOSIS TREATMENT. IMPORTANT POINTS BEFORE HISTORY-TAKING.

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HISTORY TAKING FROM A PATIENT

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  1. HISTORY TAKING FROM A PATIENT M K Alam MS,FRCS Professor of Surgery

  2. PATIENT’S PROBLEM HOW TO SOLVE IT? • HISTORY • CLINICAL EXAMINATION • CLINICAL DIAGNOSIS • INVESTIGATIONS • FINAL DIAGNOSIS • TREATMENT

  3. IMPORTANT POINTS BEFORE HISTORY-TAKING • Introduce yourself • Explain yourself • Full attention • Treat with respect • Let patient talk • Guide, not dictate • No leading question • No short-cuts • Try not to write and talk to the patient at the same time

  4. Different parts of a history • PERSONAL DETAILS • PRESENTING COMPLAINT • HISTORY OF PRESENT ILLNESS • SYSTEMIC INQUIRY • PAST MEDICAL/SURGICAL HISTORY • FAMILY HISTORY • HISTORY OF MEDICATIONS • SOCIAL HISTORY • OTHER HISTORY

  5. PERSONAL DETAILS • NAME • AGE • SEX • NATIONALITY • MARITAL STATUS • OCCUPATION Record date of history taking and examination

  6. PRESENTING COMPLAINT • What are you complaining of? (record in patient’s own words) • When more than one complain: (record in order of severity)

  7. HISTORY OF PRESENT ILLNESS • Full details of the complaint or complaints. • Get right back to the beginning of the trouble. • Each complain- fully analyzed e.g., pain • Site • Time and mode of onset ( sudden, gradual) • Severity • Nature (aching, burning, stabbing, constricting, throbbing) • Progression • Duration • Aggravating/ relieving factors • Radiation • Cause

  8. SYSTEMIC INQUIRY of the involved or affected system Example: Chief complaint related to gastrointestinal system(GI)- continue with the GIT inquiry.

  9. SYSTEMIC INQUIRY GASTRINTESTINAL SYSTEM • Weight • Appetite • Dysphagia • Nausea • Vomiting • Heartburn • Haematemesis • Flatulence • Jaundice • Abdominal pain • Fat intolerance • Constipation • Diarrhoea • Melaena • Rectal bleeding • Stool

  10. SYSTEMIC INQUIRY RESPIRATORY SYSTEM • Cough • Sputum • Hemoptysis • Wheeze • Dyspnoea • Chest pain • Smoking

  11. SYSTEMIC INQUIRY UROGENITAL SYSTEM • Loin pain • Dysuria • Nocturia • Frequency • Haematuria • Urinary stream • Incontinence • Urethral discharge

  12. SYSTEMIC INQUIRY CARDIOVASCULAR SYSTEM • Angina (cardiac pain) • Dyspnoea ( rest/ exercise) • Palpitations • Ankle swelling • Claudication • Varicose veins

  13. SYSTEMIC INQUIRY Obstetric & Gynecology • LMP • Vaginal discharge • Vaginal bleeding • Pregnancies Nervous system • Headache • Fits • Depression • Facial/limb weakness

  14. SYSTEMIC INQUIRY MUSCULOSKELETAL • Muscular pain • Bone & Joint pain • Swelling of joints • Limitation of movements • Weakness

  15. SYSTEMIC INQUIRY METABOLIC/ENDOCRINE • Bruising/ bleeding • Sweating • Thirst • Pruritus • Alcohol • Weight

  16. PAST MEDICAL/SURGICAL HISTORY • Rheumatic Fever • Tuberculosis/ Asthma • Diabetes • Jaundice • Operations/ Accident • Blood transfusion • Mental illness

  17. FAMILY HISTORY • Diabetes • Hypertension • Heart disease • Malignancy • Cause of death Father/Mother/Siblings/Spouse/Children/Close relatives

  18. HISTORY OF MEDICATIONS • Insulin • Steroids • NSAID • Contraceptive pills • Antibiotics • Others

  19. SOCIAL HISTORY • Marital status • Occupation • Travel abroad • Accommodation • Habits ( smoking, alcohol ) • Dependent relatives

  20. OTHER HISTORY • Psychiatric/ Emotional background • Allergies Food Drugs • Immunizations Tetanus Diphtheria Tuberculosis Hepatitis Others

  21. Review and analyse • More questions looking for clues?

  22. Thank you!

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