Podcast
Questions and Answers
What is the primary purpose of history taking in medicine?
What is the primary purpose of history taking in medicine?
- To establish a friendly relationship with the patient.
- To conduct a physical examination.
- To determine the underlying cause of a patient's illness. (correct)
- To immediately prescribe medication.
In medical history taking, what does the quality of communication between the patient and doctor influence?
In medical history taking, what does the quality of communication between the patient and doctor influence?
- The speed of diagnosis.
- The accuracy and completeness of the patient's history. (correct)
- The level of trust the patient has with the doctor.
- The doctor's ability to bill for services effectively.
Why is it important to greet a patient by their name during history taking?
Why is it important to greet a patient by their name during history taking?
- To quickly verify the patient's identity.
- To make the patient feel obligated to answer questions.
- To demonstrate respect and establish a personal connection. (correct)
- To comply with hospital regulations.
Which of the following is a key component of personal history in medical history taking?
Which of the following is a key component of personal history in medical history taking?
Why is it important to ask about a patient's special habits, like smoking, during history taking?
Why is it important to ask about a patient's special habits, like smoking, during history taking?
What information do 'pack-years' provide in a patient's smoking history?
What information do 'pack-years' provide in a patient's smoking history?
During history taking, what is the best approach when asking patients about their presenting complaint?
During history taking, what is the best approach when asking patients about their presenting complaint?
When documenting a patient's presenting complaint, what detail is crucial to note besides the symptoms themselves?
When documenting a patient's presenting complaint, what detail is crucial to note besides the symptoms themselves?
When exploring the history of a presenting complaint, what does 'onset' refer to?
When exploring the history of a presenting complaint, what does 'onset' refer to?
Why is it important to ask about the aggravating and relieving factors related to a patient's symptoms?
Why is it important to ask about the aggravating and relieving factors related to a patient's symptoms?
Why is it important to inquire about a patient's past history during medical history taking?
Why is it important to inquire about a patient's past history during medical history taking?
In the context of past medical history, what is the significance of asking about blood transfusions?
In the context of past medical history, what is the significance of asking about blood transfusions?
Why is it important to ask patients about drug sensitivities during history taking?
Why is it important to ask patients about drug sensitivities during history taking?
What is the primary reason for inquiring about a patient's family history?
What is the primary reason for inquiring about a patient's family history?
What does the term 'first-degree relatives' refer to when discussing family history?
What does the term 'first-degree relatives' refer to when discussing family history?
What physiological process underlies most allergies?
What physiological process underlies most allergies?
What reaction commonly indicates allergic rhinitis?
What reaction commonly indicates allergic rhinitis?
When taking a patient's history regarding allergies, why is it crucial to ask about allergies to drugs, foods, and environmental factors?
When taking a patient's history regarding allergies, why is it crucial to ask about allergies to drugs, foods, and environmental factors?
What factors does 'social and economic status' include?
What factors does 'social and economic status' include?
Why is it important to ask about the presence of pets in the house when discussing social and economic status?
Why is it important to ask about the presence of pets in the house when discussing social and economic status?
In the context of a female patient's menstrual history, what does 'age of menarche' refer to?
In the context of a female patient's menstrual history, what does 'age of menarche' refer to?
Why is it important to ask about the regularity and duration of menstrual cycles during history taking?
Why is it important to ask about the regularity and duration of menstrual cycles during history taking?
In obstetric history taking, what information is gathered regarding previous pregnancies?
In obstetric history taking, what information is gathered regarding previous pregnancies?
When obtaining a patient's obstetric history, why is it important to inquire about gestational diabetes?
When obtaining a patient's obstetric history, why is it important to inquire about gestational diabetes?
What does 'OLD CARTS' refer to in the context of history taking?
What does 'OLD CARTS' refer to in the context of history taking?
What is the purpose of asking about the 'course' of the presenting complaint?
What is the purpose of asking about the 'course' of the presenting complaint?
What should be avoided when taking a patient's presenting complaint?
What should be avoided when taking a patient's presenting complaint?
Which of the following is NOT typically included in the past history section during medical history taking?
Which of the following is NOT typically included in the past history section during medical history taking?
What is a 'special habitat' of medical importance mentioned in the content?
What is a 'special habitat' of medical importance mentioned in the content?
A patient says they have smoked one pack of cigarettes everyday for 20 years, how many 'pack years' is that?
A patient says they have smoked one pack of cigarettes everyday for 20 years, how many 'pack years' is that?
Which component of history taking provides insights into potential exposure to communicable diseases?
Which component of history taking provides insights into potential exposure to communicable diseases?
What immediate action should a healthcare provider prioritize upon discovering a patient's allergy to a commonly prescribed medication?
What immediate action should a healthcare provider prioritize upon discovering a patient's allergy to a commonly prescribed medication?
Which aspect of a patient's social history is most relevant in evaluating their overall health risk related to environmental factors?
Which aspect of a patient's social history is most relevant in evaluating their overall health risk related to environmental factors?
In the context of family history, why is it important to inquire specifically about illnesses in first-degree relatives?
In the context of family history, why is it important to inquire specifically about illnesses in first-degree relatives?
What key aspect of a female patient’s reproductive history provides critical information about their hormonal status and potential fertility?
What key aspect of a female patient’s reproductive history provides critical information about their hormonal status and potential fertility?
Among the factors considered in a patient's obstetric history, which one most directly informs the risk of complications in future pregnancies?
Among the factors considered in a patient's obstetric history, which one most directly informs the risk of complications in future pregnancies?
When assessing the "nature" of a presenting complaint, what specific details are you aiming to uncover?
When assessing the "nature" of a presenting complaint, what specific details are you aiming to uncover?
What key information is essential when documenting drug sensitivities?
What key information is essential when documenting drug sensitivities?
Which of the following scenarios would MOST warrant further investigation into a patient's environmental exposures during history taking?
Which of the following scenarios would MOST warrant further investigation into a patient's environmental exposures during history taking?
Flashcards
What is history taking?
What is history taking?
The process of a physician gathering information by asking specific questions to a patient.
Importance of History Taking
Importance of History Taking
An accurate patient history is a critical first step in determining the cause of an illness.
How to take history?
How to take history?
Good communication between patient and doctor is key for a true history.
How to greet your patient?
How to greet your patient?
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Components of history taking
Components of history taking
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Personal History Elements
Personal History Elements
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Smoking risks
Smoking risks
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How to calculate a pack-year
How to calculate a pack-year
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Alcohol & Drugs
Alcohol & Drugs
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Presenting Complaint Guidelines
Presenting Complaint Guidelines
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History of Presenting Complaint
History of Presenting Complaint
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OLD CARTS
OLD CARTS
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Past History
Past History
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Drug Sensitivities
Drug Sensitivities
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Family History
Family History
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What is an allergy?
What is an allergy?
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Common allergy symptoms
Common allergy symptoms
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Common Allergens
Common Allergens
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Social and Economic Status
Social and Economic Status
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Menstrual History
Menstrual History
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Obstetric History
Obstetric History
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Study Notes
- The process by which a physician gains information by asking specific questions to patient known as medical history taking
- Obtaining an accurate history is a critical first step in determining the etiology of a patient's illness
- Diagnosis in medicine depends on: clinical history, physical examination, and investigation
- Good communication between the patient and doctor is the basis of true history
- History taking requires practice, patience, concentration, and understanding
Approaching the Patient
- Greet the patient by name
- Make eye contact
- Display confidence
- Explain the plan of care and involve the patient in decision making
- Maintain patient privacy
- Be alert and pay attention
Components of History Taking
- Personal history
- Chief complaint
- History of present illness
- Past history
- Family history
- History of allergies
- Social and economic status
- For females, menstrual and obstetric history
Personal History
- Name
- Age
- Sex
- Occupation
- Marital status
- Residence
- Special habits
Special Habits
- Smoking can damage every part of the body
- Risks include cancers of the head, neck, and lung
- Risks also include chronic diseases like stroke, blindness, gum infection, aortic rupture, heart disease, and pneumonia
Calculating Pack-Year
- Multiply the number of packs per day by the number of years smoked
- Example: A patient has smoked 5 packs per day for 10 years, so (5 packs per day) x (10 years) = 50 pack-year smoker
Presenting Complaint
- Allow the patient to tell his complaints in his own words
- Avoid leading questions
- Note the current complaints and their duration in chronological order
- Example: Difficulty in breathing since this morning
History of Presenting Complaint
- Onset
- Nature
- Course
- Associated symptoms
- Duration of each symptom
- Aggravating and relieving factors
OLD CARTS Mnemonic for Symptom Assessment
- O - Onset: acute vs. gradual
- L - Location
- D - Duration
- C - Characteristics
- A - Aggravating factors
- R - Relieving factors
- T - Treatments (and response)
- S - Severity
Past History
- Ask if the patient presented with similar complaints in the past
- If present, ask when and how frequently they are having these episodes
- History of blood transfusion
- History of operation
- History of any medication
- History of drug sensitivity
- History of travel abroad
Drug Sensitivities
- Some people are allergic or sensitive to drugs that are not harmful for most people
- Drugs like aspirin, penicillin, or related antibiotics may induce allergic reactions in some children and sensitivities in others
Family History
- Detail the family history
- Ask if there are any illnesses that run in the family
- Basic family tree of first-degree relatives
History of Allergies
- Allergies are hypersensitive responses from the immune system to substances that either enter or come into contact with the body
- Common presentations include: cold, cough, sneezes, rashes, and facial edema
Common Allergens
- Dust
- Mites
- Pollen
- Some kinds of foods
- Drugs
Social and Economic Status
- Enquire about the patient's family life style, daily habits, and diet
- Nature of the patient's work (hard work or sedentary)
- Possibility of overcrowding at home, which aids in the spread of communicable diseases, and the sanitation in and around the house
- Presence of pets in the house
Menstrual History
- Age of menarche
- Duration of each cycle
- Regular or irregular cycles
- Volume of blood loss in each menstrual cycle
- Age of attainment of menopause
- Post-menopausal bleeding
Obstetric History
- Number of times the patient conceived
- Number of times pregnancy was carried to term
- Number of abortions
- Number of living children, their ages, and the age of the last child delivered
- The time interval between successive pregnancies/abortions
- Mode of delivery (vaginal, forceps assisted, or caesarean)
- Development of oedema legs, hypertension, or seizures in the antenatal or postnatal period
- Gestational diabetes
- Tubectomy or Hysterectomy
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