History Taking PDF

A History taking General approach in the beginning of the patient interview 1. Greet the patient and be friendly 2. Introduce yourself: give your name and your job (e.g. Dr. Mohamed, ward doctor or medical student) 3. Confirm you’re speaking to...

A History taking General approach in the beginning of the patient interview 1. Greet the patient and be friendly 2. Introduce yourself: give your name and your job (e.g. Dr. Mohamed, ward doctor or medical student) 3. Confirm you’re speaking to the correct patient (name and date of birth) 4. Patient permission for all issues 5. Ensuring privacy and confidentiality of patient’s information 6. Positioning: patient sitting in chair approximately a meter away from you. Ensure you are sitting at the same level as them and ideally not behind a desk. 7. Maintain eye contact, active listening and avoid any interruptions History taking includes: 1. Personal history 2. Complaint 3. History of present illness 4. Past medical history 5. Family history 6. Nutritional history 7. Psychological history 8. Social history 9. Immunization history 10.Screening history 11.Idea, concern, expectation Personal history  Name of the patient: to be familiar with the patient  Age: as certain diseases are more common in certain ages  Sex: some disorders are more common in men such as abdominal aortic aneurysms. In contrast, women more commonly have autoimmune problems, such as systemic lupus erythromatosus. Also, the possibility of pregnancy must be considered in any women in child bearing period.  Occupation: certain occupation may increase patient’s risk to certain diseases A  Marital status: for possible sterility or impotence  Residence: may point to endemic diseases in addition may reflect socioeconomic stats.  Special habits of medical importance that increase patient susceptibility to certain disease (smoking, over the counter medications, drug abuse, alcoholism) Complaint: the main complaints plus duration  Ask the patient to describe their problem using open questions (e.g. “What’s brought you into hospital today?”)  The presenting complaint should be expressed in the patient’s own words (e.g. “I have tightness in my chest.”)  Do not interrupt the patient’s first few sentences if possible No medical terms  As short as possible History of present illness 1. Analysis of the complaint 2. Symptoms of related system 3. Other systems review 4. Investigation and treatment Characterized by: As long as possible in chronological manner in the form of history 1. Analysis of the complaint The analysis of any complaints includes  Onset, course, duration  Association  What increase and what decrease  Effect of treatment  Previous similar conditions A A useful mnemonic for pain is “SOCRATES “ - Site - Onset, course, duration - Character - Radiation - Alleviating factors - Timing - Exacerbating factors - Severity (1-10) For any excreta (vomiting, diarrhea, urine); ask about amount, content, color, consistency and odor 2. Symptoms of related system It is important to include “pertinent positives” and “pertinent negatives” from reviewing the symptoms related to the Chief Complaint(s). These designate the presence or absence of symptoms relevant to the differential diagnosis, which refers to the most likely diagnoses explaining the patient’s condition. Such as if the chief complaint was abdominal pain, other GIT symptoms should be reviewed thoroughly. 3. Other systems review Reviewing other system is relevant to the differential diagnosis, illicit other ignoring symptoms. Other information is frequently relevant, such as risk factors for coronary artery disease in patients with chest pain, or expected complications in diabetic patients. Run through a full list of symptoms from major systems:  Cardiovascular: chest pain, palpitations, peripheral edema, paroxysmal nocturnal dyspnea (PND), orthopnea  Respiratory: Cough, shortness of breath (and exercise tolerance), hemoptysis, sputum production, wheeze  Gastrointestinal: Abdominal pain, dysphagia, heartburn, vomiting, hematemesis, diarrhea, constipation, rectal bleeding  Genitourinary: Dysuria, discharge, lower urinary tract symptoms  Neurological: Numbness, weakness, tingling, blackouts, visual change  Psychiatric: Depression, anxiety  General review: Weight loss, appetite change, lumps or bumps (nodes), rashes, joint pain 4. Investigation and treatment A The present illness should reveal the patient’s responses to his or her symptoms and what effect the illness has had on the patient’s life.  Medications should be noted, including name, dose, route, and frequency of use. Also list home remedies, nonprescription drugs, vitamins, mineral or herbal supplements, birth control pills, and medicines borrowed from family members or friends. It is a good idea to ask patients to bring in all of their medications so you can see exactly what they take.  Smoking index, Alcohol and drug use should always be queried (Note that tobacco, alcohol, and drugs may also be included in the Personal and Social History; however, many clinicians find these habits pertinent to the Present Illness.)  Chronic disease : Major illnesses such as hypertension, diabetes, bronchial asthma, heart failure, Past medical history  Major illnesses such as hypertension, diabetes, bronchial asthma, heart failure, angina or stroke should be detailed: 1. Age of onset, severity, end organ involvement 2. Medications taken for the particular illness including any recent changes to medications and reason for the change 3. Last evaluation of the condition (eg, when was the last stress test in patient with angina) 4. Which physician or clinic is following the patient for the disorder?  Minor illness such as recent bronchitis  Hospitalizations, reasons and for how long should be queried  Blood transfusion  Allergies: including specific reactions and severity to each medication, such as rash or nausea, must be recorded, specifically ask about whether there’s been a history of anaphylaxis e.g. “allergy with hypotension, throat swelling, and trouble breathing or puffy face”. In addition, allergies to foods, insects, or environmental factors. Past surgical history: 1. Date and type of procedure performed, indication and outcome. 2. Surgeon and hospital name/ location should be listed 3. Any complications should be queried including anesthetic complications, difficult intubations and so on. A Family history  Ask the patient about any family diseases relevant to the presenting complaints (e.g. if the patient has presented with chest pain, ask about family history of heart attacks).  Many major medical problems are genetically transmitted (eg, hemophilia, sickle cell disease)  Family history of conditions such as ischemic heart diseases, diabetes mellitus and hypertension can be a risk factor for the development of these diseases.  Enquire about the patient’s parents and sibling and, if they were deceased below 65, the cause of death. Nutritional history  Inquire about the patient’s usual weight and ask if there have been any weight changes. Weight loss of >10% of body weight can signify underlying pathology. Weight gain can be suggestive of various underlying endocrine pathologies. Weight gain can also lead to insulin resistance contributing to metabolic syndrome.  Ask about eating habits and dietary preferences. For example, ask about the number of meals eaten in a day, approximate portion sizes, whether they are following any restrictive diets, whether they are vegan or vegetarian, or if they are allergic to any food items. This can help in diagnosing a possible nutritional deficiency  Current nutrient and fluid intake should be recorded. Methods such as the 24-hour recall method  Ask if there are any symptoms suggestive of malnutrition other than weight changes, such as rashes, sores in the mouth, dryness of skin and eyes, loss of night vision, hair loss, and bleeding gums, poor healing of wounds, swelling of extremities, tingling, or numbness.  If patients are on any nutritional supplements, care must be taken to record the frequency and dosage to limit the risk of nutrient insufficiency and toxicity.  Ask about any factors affecting food intake, like poor dentition, ulceration in the oral cavity, difficulty in swallowing, loss of appetite, heartburn, nausea, and/or vomiting. Further, inquire about bowel habits. Menstrual ,contraceptive and obstetric history (for females )  Date of Menarche and menopause. A  Date of last menstruation.  Frequency of the periods, regularity, duration, amount of blood.  History of intake of contraceptive pills. Psychological history:  Ask about Psychiatric illness (include dates, diagnoses, hospitalizations, and treatments).  Assess tendencies towards depression or anxiety is important: ask for low mood and loss of interest in the last two weeks. Social history  Ask questions related to lifestyle habits (active vs. sedentary), daily physical activities, and exercise routine.  History about social habits such as drinking, smoking, tobacco consumption, or other non-prescription drugs should also be taken.  Home situation and significant others; family support, sources of stress, both recent and long-term, coping styles; important life experiences, such as military service, job history, financial situation, and retirement; leisure activities; religious affiliation and spiritual beliefs; and activities of daily living (ADLs)  Conveys lifestyle habits that promote health or create risk such as exercise, including frequency of exercise, and safety measures, including use of seat belts, bicycle helmets. Further social history is required depending on the type of presenting complaint for example:  Respiratory presenting complaint: Ask about pets, dust exposure, asbestos, exposure to the farms, exposure to birds or if there are any hobbies  Infectious to disease related: Ask for a full travel history including all occasions exposure to water, exposure to foreign food, tuberculosis risk factors, HIV risk factors, recent immunizations Immunization history: such as tetanus, pertussis, diphtheria, polio, measles, rubella, mumps, influenza, hepatitis B, Haemophilus influenza type b, and pneumococcal vaccines (these can usually be obtained from prior medical records) A Screening history: ask about recent investigations or examinations done for health maintenance such as tuberculin tests, Pap smears, mammograms, stools for occult blood, and cholesterol tests, together with the results and the dates they were last performed. If the patient does not know this information, written permission may be needed to obtain old medical records. Idea, concern and expectations Asking about a patient’s ideas, concerns and expectations allow doctors to gain insight into how a patient currently perceives their situation, what they are worried about and what they are expecting from the consultation. Example of how to explore a patient’s idea, concern and expectations: “Tell me about what you think is causing the problem.” “Are you worried about this being anything in particular?” “What do you think might be the best plan of action?” After collecting relevant history, ask patient permission in performing complete general and local examination with ensuring patient’s privacy, infection control measures including hand hygiene. General approach in the end of the patient interview (closure of patient interview)  Respond to ICE  Respond to investigations.  Management plan and patient education:- 1. Diagnosis 2. Treatment (pharmacological and non-pharmacological management) 3. Follow up 4. Red flags or safety netting 5. Referral if indicated  Check patient understanding  Any questions  Offer availability  Thank the patient  General examination Mentality Body built Complexion Decubitus Expression Vital signs Regional examination Mentality: Normal: conscious alert oriented to time person and place. Abnormal: unconscious or altered consciousness. Body built: BMI=Weight\(height)2 Normal =average weight. Abnormal: 1. Underweight. 2. Overweight 3. Obese. Complexion : Normal. Abnormal: pallor, cyanosis and jaundice.(generalized pigmentation ,rash ,vascular lesions) Decubitus : Position preferred by patient in bed. Normal: patient is lying comfortable in bed. Examples: Orthopnea. (Heart failure). Prayer`s position (aortic aneurysm). Jaundice  Pallor Cyanosis Vital signs. Pulse Examination Importance: Pulse measurement provides information about heart rate, rhythm, and the strength of blood flow. It helps identify conditions like arrhythmias, tachycardia, and bradycardia. Normal Range: Adults: 60-100 beats per minute (bpm) Tachycardia: >100 bpm Bradycardia: