History Taking in Medical Practice

History Taking

• The presentation is about history taking in medical practice.
• Key components of a medical history include medical history, case history, and anamnesis.
• Symptoms, clinical signs, differential diagnosis, and history and physical examinations are important aspects of the process.
• Introduce yourself carefully.
• Identification, including date of birth, sex, and ethnicity, is crucial.
• Patient's name: James Taylor
• Age: 55
• Height: 5' 8"
• Weight: 170 lbs
• Chief complaints: Biliary colic pain, sweating, and yellow skin.
• Pain scale: 9
• Body temperature: 39.8°C (103.6°F)

History of Presenting Complaint (HPC)

• The presentation follows the "OLDCARTS" framework to record patient complaints related to the presenting illness or symptoms.
• A framework such as SOCRATES can also be used, and includes site, onset, character, quality, timing, exacerbation, relief, severity, and associated symptoms.
• The presentation shows a dedicated pain assessment model, which helps in evaluating pain by assessing location, onset, characteristics, radiation, time-duration, exacerbating factors, relieving factors, associated symptoms, and severity,
• Other pain assessment tools and scales are mentioned, including a universal scale with a visual analogue scale and Wong-Baker facial grimace scale. The scale runs from 0 to 10.

Past Medical History

• Gathering information on patient's past medical history is crucial.
• The presentation highlights the importance of past medical history, past surgical history, symptoms, allergies, medications, pertinent medical history, last meal, and any events leading to the patient's condition.

Social History

• Includes smoking history and pack-years.
• Details about alcohol consumption, classified as frequent excessive drinker, occasional excessive drinker, moderate drinker, and abstainer.
• Using the alcoholic beverages strength and volume to calculate the number of units of alcohol.

Review of Systems (ROS)

• Review of systems (ROS) is a method to assess physical conditions across various body systems.
• The systems included in the review are brain, upper body, chest, lungs, stomach, skin, and whole body.
• Specific symptoms and concerns of each body system are listed, such as lightheadedness, dizziness, pain, discomfort, shortness of breath, nausea, cold sweat, and fatigue, and more.

Family Information

• Understanding family history is critical for diagnosis.
• The presentation highlights the collection of family information through a family tree and pedigree.

Patient Feedback

• Patient feedback is essential for understanding expectations.
• The illustration show patient feedback discussions to ensure accurate communication.

Inhibiting Factors

• The illustration shows challenges and obstacles.
• Factors that might prevent the successful achievement of a goal.

Summary of History

• A summary of the collected history is crucial.
• Key information collected during the history taking process for the patient are listed, together with any allergies, drug reactions, current medications, and past medical history, cholesterol levels, family history of gallstones, and more.

Concluding Remarks

• The presentation ends with a polite closing message from the doctor.