History Taking PDF
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Uploaded by Dylario
Tishk International University
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Summary
This document provides an overview of history taking in a medical context. It details the importance and process of gathering patient information, outlining steps and components such as patient profiles, chief complaints, medical history, and medications for accurate diagnosis and treatment planning. It mentions the SOCRATES method, a framework used to obtain detailed symptoms.
Full Transcript
History taking Historytaking: is a process when a doctor asks a patient questions to gather information for diagnosing and treating them. A largepercentageofthetime(70%), you willactually be able make a diagnosis based on the history alone. How to take a History: a true history is good...
History taking Historytaking: is a process when a doctor asks a patient questions to gather information for diagnosing and treating them. A largepercentageofthetime(70%), you willactually be able make a diagnosis based on the history alone. How to take a History: a true history is good communication between doctor/ nurse and patient. Ittakes practice, patience, understanding and concentration. Important of History Taking History Taking is the first step in determining the aetiology of a patient's illness. Diagnosis in medicine is based on Clinical history Physical Examination Investigations The purpose of obtaining a history is to: Collect a systematic account of past medical conditions, illnesses, and injuries. Determine the present medical situation. Determine the signs and symptoms of the current condition. Approach to history taking: 1. Your look is important, your dressing. 2. Introduce your self and create a rapport. 3. Be alert and pay full attention. 4. Ensure consent has been gained. 5. Maintain privacy. 6. Ensure the patient is as comfortable as possible. 7. Summaries each stage of the history taking process. 8. Involve the patient in the history taking process. Components of History taking: 1. Patient’s profile 2. Chief complaint 3. History of the present illness 4. Past medical history 5. Family history 6. Socioeconomic history 7. System Review Personal Information (Patient’s profile): 1. Date and Time 2. Name Age Sex 3. Nationality 4. Religion 5. Marital status 6. Occupation 7. Address 8. Who gave the history? Chief Complaint: 1. Main reason for seeking medical help. 2. Usually one symptom (e.g., fever, headache, pain). 3. Described in patient's own words. 4. Record with onset and duration. Chief Complaint: Route of Admission: Time of Admission: Complaining of: When did it start? History of Presenting Illness: SOCRATES (Associated Symptoms) Site: Localized Onset: ○ Sudden or gradual? Character: ○ (pressure/colicky/dull) ○ Increase, decrease or constant? ○ Comes and goes or persistent? ○ Affected by respiration? Radiation: Time: Exacerbated by: Relived by: Severity: FFLLNN (Constitutional symptoms) ○ Fever ○Fatigue ○Loss of wight ○Loss of appetite ○Nausea ○Night sweat: MEDICATIONS: Drug: Reason of taking the drug: Route of Administration: Dose: Duration: Complications: Compliance: Yes/No (if no, Why?) Herbal medications
