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History

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Inam Ullah
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6 views14 pages

History

Uploaded by

Inam Ullah
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd
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HISTORY

TAKING
Prepared by
Tufail Ahmad
HISTORY TAKING
 The history is a patient’s account of their illness together with other
relevant information you have gleaned from them.
 The history of a patient is information gained by a physician by asking
specific questions, either of the patient or of other people who know the
person and can give suitable information.
 The method by which doctors gather information about a patient’s past and
present medical condition in order to make informed clinical decisions is
called the history and physical examination.
HISTORY TAKING
 History-taking
 Patient profile (PP)
 Chief complaint (CC)
 History of present illness (HPI)
 Past medical history (PMH)
 Allergies
 Drug history
 Alcohol
 Smoking
HISTORY TAKING
 Family history (FH)
 Social history (SH)
 Review of systems (ROS)
PATIENT PROFILE (PP)
 This is the essential identifying and biographic information required by the
facility.
 Typically included in the PP will be the patient’s name, address, and DOB.
 Other information included in the PP may include age, religion, nationality,
marital status, and contact information as requested by the individual
facility.
CHIEF COMPLAINT
 This is the patient’s chief symptom(s) in their own words.
 It should generally be no more than a single sentence.
 Ask the patient an open question, such as, “What’s the problem?”
 Each provider will have their own style. You should choose a phrase that
suits you and your manner (one of the authors favors saying “tell me the
story” after a brief introduction).
 Remember, the CC is expressed in the patient’s words. “Hemoptysis”
is rarely a presenting complaint, but “coughing up blood” may well be
HISTORY OF THE PRESENT
ILLNESSES
 Here you are asking about and documenting details of the presenting
complaint of how and when it is started.
 how it has progressed over time, and what impact it has had on the patient
in their general physical health, psychology, and social and working lives.
 Ask an open question (as for the CC) and allow the patient to talk through
what has happened for about 2 minutes.
 Don’t interrupt! Encourage the patient with nonverbal responses and take
discreet notes.
 Date it began
 How it began
 Is the symptom constant or intermittent?
HISTORY OF THE PRESENT
ILLNESSES
 How long does it last each time?
 What is the exact manner in which it comes and goes?
 Is it improving or deteriorating?
 What makes the symptom worse?
 What makes the symptom better?
 Associated symptoms
HISTORY OF THE PRESENT
ILLNESSES
 For pain, determine
 site (where is the pain is worst—ask the patient to point to the site
with one finger)
 Radiation (does the pain move anywhere else?)
 Character (i.e., dull, aching, stabbing, burning)
 Severity (scored out of 10, with 10 being the worst pain imaginable)
 Mode and rate of onset (how did it come on—over how long?)
 Duration
 Frequency
 Relieving factors, Associated symptoms
PAST MEDICAL HISTORY
 Here, you should obtain detailed information about past illnesses and
surgical procedures.
 Ask the patient if they are receiving care for anything else or have ever
been to the hospital before.
 When was it diagnosed?
 How was it diagnosed?
 How has it been treated?
ALLERGIES
 Ask if the patient has any allergies or is allergic to anything if they are
unfamiliar with the term allergies.
 Ask specifically if they have had any reactions to drugs or medication;
don’t forget to inquire about food or environmental allergies.
 If an allergy is reported, you should obtain the exact nature of the event
and decide if the patient is describing a true allergy, intolerance, or simply
an unpleasant side effect.
DRUG HISTORY
 Here you should list all the medications that the patient is taking, including
the dosage and frequency of each prescription.
 If the patient is unsure about their medications, confirm the drug history
with the prescribing provider or pharmacy.
 Take special note of any drugs that have been started or stopped recently.
ALCOHOL AND SMOKING
 You should attempt to quantify, as accurately as possible, the amount of alcohol
consumed per week, and establish if the consumption is spread out evenly over the
week or concentrated in a smaller period.

smoking
Ask about previous smoking, as many patients will call themselves nonsmokers if they
gave up yesterday or are even on their way to the hospital
or clinic!
FAMILY HISTORY
 You should ask about any diagnosed conditions in other living family
members.
 Social history
 This is a vital part of the history but is often given only brief attention.

 Marital status
 Orientation

 Occupation

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