ECPD1 Basic Principles of History Taking PDF

University of Alkafeel College of Medicine ECPD1 Basic Principles of History Taking Dr Hayder Almayali ECPD Organizer This lecture will attempt to: 1) Define History Taking. 2) Explain the importance of history taking in making the d...

University of Alkafeel College of Medicine ECPD1 Basic Principles of History Taking Dr Hayder Almayali ECPD Organizer This lecture will attempt to: 1) Define History Taking. 2) Explain the importance of history taking in making the diagnosis. 3) Identify the main components of the history taking framework (steps to be followed) 4) Demonstrate the importance of good communication skills in history taking. 5) State the importance of good recording of patient’s history. What is History Taking? In each clinical case (a patient with a disease) a doctor faces, there are steps to be followed to help the patient by making the correct diagnosis (‫ )التشخيص‬so that the correct treatment (‫ )العالج‬is to be decided to cure the disease. These steps are: 1) Talk to the patient to know what is his complaint. (‫)سماع شكوى المريض‬. This is called “History Taking”. 2) Examine the patient to discover signs of the disease (‫ )عالمات المرض‬.This is called “Clinical Examination” (‫)الفحص السريري‬. 3) Do the investigations to prove the diagnosis (‫)التحاليل المختبرية و األشعات‬. By these three steps, a doctor should reach a diagnosis to start treating his patient. Of these three steps, history taking is very important as it’s step that will decide the direction in which the other steps (examination and investigations) will be made, as the doctor should “suspect” a disease after taking the disease’s history. The history taking is also important to create the necessary bond with the patient that helps delivering the medical service necessary to the patient, as the patient needs to believe in and trust his doctor to follow his instructions and guidance in treatment. So: History + Examination+ Investigations= Diagnosis Good and effective history taking needs the following: 1) The doctor should be patient (‫ )صبور‬and a good listener. Don’t interrupt your patient. 2) The doctor should respect the patient’s privacy (‫)خصوصية‬. 3) The doctor uses a language the patient can understand. This is called good “Communication”. 4) The doctor shows sympathy (‫ )تعاطف‬to the patient. This is called “Professionalism”. So, history taking is the conversation a doctor makes with his patient to know all the details of the complaint of the patient and the associated problems (present and past) that enables the doctor to suspect a diagnosis and then direct (‫ )يو ّجه‬the next steps in a way that helps to reach the diagnosis. Remember, the patient has confided (‫ )وثق بك و أأتمنك‬with his condition; so keep it as a secret. This is called “Confidentiality”. How should I take history from my patient? 1) Before you start, you should: * Introduce yourself to the patient (your name and job), which is the first step in making a good link and ensures your patient’s trust. * Ask for permission (called “Consent”): ‫أحصل على موافقة المريض ألجراء الحوار‬ * Ensure a proper and comfortable place to talk to your patient. 2) Follow an organized (systematic) way in talking the history so that you don’t miss any piece of information: Parts (steps) of the history taking: 1) Demographic data (who is my patient?) 2) Chief complaint and duration (what brought him to the doctor) 3) History of present illness (how this present problem happened?) 4) Review of systems (how is his general health?) 5) Past medical and past surgical history (‫)األمراض المزمنة و العمليات الجراحية السابقة‬ 6) Drug history (‫)األدوية التي يستعملها المريض حاليا‬ 7) Family history (‫)األمراض الوراثية‬ 8) Social history (‫)العادات و طبيعة الحياة التي يعيشها المريض‬ Demographic data: These are important to correctly identify your patient, building a trust with them, expect the life style of the patient: Name Age Address Occupation (Job): some occupations create a risk to develop certain diseases. Marital status. Chief complaint and duration: This is simply described as: what caused the patient to visit the doctor today? And since when? Examples of common (‫ )شائعة‬chief complaints are: Fever Abdominal pain, vomiting (‫ )تقيؤ‬or diarrhea (‫)إسهال‬  Chest pain (‫)ألم في الصدر‬ Lower back pain (‫)ألم أسفل الظهر‬ It is also important to know for how long (duration) this complaint has been affecting the patient, as each duration indicates different diagnosis. Use the patient’s own words in describing the complaint and analyze it. History of present illness Here, ask the patient to give you the details of his chief complaint. Use an open question (like, tell me more about your problem). A good example of the importance of this part of history is: how the patient describes his pain? Exact site? How bad? How it started (Onset)? Nature of the pain? What makes it worse or better? Review of systems This is the step where you ask about the patient’s general health by checking if your patient has a specific problem related to a body system. What is menat by body systems are: Cardiovascular system (‫)جهاز القلب و الدوران‬ Respiratory system (‫)جهاز التنفس‬ Gastro-Intestinal system (‫)الجهاز الهضمي‬ Genitourinary system (‫)الجهاز البولي‬ Nervous system (‫)الجهاز العصبي‬ For the cardiovascular system we should ask if any: chest pain, palpitation (‫ )خفقان‬or shortness of breath (‫?)ضيق بالتنفس‬ For the respiratory system: any shortness of breath, cough (‫?)سعال‬ For the gastrointestinal system: any vomiting, loss of appetite (‫)فقدان الشهية‬, loss of weight (‫?)فقدان وزن‬ For the genitourinary system: any painful micturition (‫)الم عند التبول‬, micturition frequency (‫)زيادة باألدرار‬, loin pain (‫?)ألم في الخواصر‬ For the nervous system: any headache (‫)صداع‬, change in vision (‫ )ضعف النظر‬or loss of sensation (‫?)فقدان األحساس أو الخدر‬ We check the body systems to exclude any relation to the patient’s chief complaint to try suspecting a specific diagnosis. Past medical history: * In the past medical history taking we check if the patient has any chronic disease (‫?)وجود أمراض مزمنة‬ This is because the chief complaint of the patient could be related to his chronic disease. Common examples of chronic diseases are: diabetes (‫)داء السكر‬, hypertension (‫ )إرتفاع الضغط‬or rheumatoid arthritis ("‫)إالتهاب المفاصل " الرومتتزم‬. past surgical history: * In the past surgical history we check if the patient had any surgical operations in the past? , for what reasons? And if any complications happened during or after these operations? (‫)العمليات الجراحية السابقة و أسبابها و مضاعفاتها‬.  This section of the history taking (past medical and surgical history) gives us an idea about the general health of the patient. Drugs (medications) History: In this part of the history we check what medications (‫ )أدوية‬the patient takes regularly (‫ )أدوية األمراض المزمنة‬as these medications can have certain side effects (‫)أعراض جانبية‬ related to the chief complaint of the patient or may affect our choices of the treatments for the patient. We should ask: what medications our patient takes? At what dose (‫ ?)الجرعة‬for how long the patient used this medication? And if the patient is tolerating this medication? Family history This part is to check if the patient has any family (hereditary) disease ( ‫األمراض‬ ‫ )الوراثية في العائلة‬as this can help in reaching an accurate diagnosis. Common examples of hereditary diseases are diabetes, hypertension, heart diseases. Social history It’s very important to know the social habits of the patient like smoking, alcohol drinking and how active is the patient’s life? These factors strongly affect the general health of the patient and can be a direct cause of the chief complaint of the patient. How to end the conversation? 1) Thank the patient. 2) Tell the patient your impression and suspects. 3) Inform the patient that you should do the clinical examination and to arrange also for the investigations before you can be sure about the diagnosis. 4) Be sure that have documented (‫ )سجلت‬all the information you gained from the conversation as these will be the basis for the follow up (‫ )متابعة‬of the patient and they are very important for research works. Thank You