UNIVERSITY OF BASRAH Ministry of higher Education

AL-ZAHRAA MEDICAL COLLEGE and Scientific Researches

The module: Consultation Skill Foundation Course (CSFC)

History Taking
week one, lec. 2 .
Module Staff:
Dr. Haithem Hussein Ali Dr .Falih Waheed Dr. Firas Rasheed
Dr. Jawad Ramadhan Fadhl Dr. Waleed Jawad Dr.Mohammed Adil
Dr. Wisam Hamza Abbas Dr. Ahmed Ibrahim Dr. Ahmed Hakim
Dr. Ahmed Mohammed Dr. Rafid Mosa Dr. Ammar Mohammed
Dr. Thura Kadhim Ja’afar Dr. Khalil Ibrahim Dr. Miami Kadhim Yousif
Dr. Safaa Taha Dr. Raed Jassib Dr. Rihab Abdulwahad
Dr. Sadik Hassan Kadhem Dr. Abdulrazaq Jassim Dr. DhagemEmad
Dr. Abbas Jumaa Dr. Ahmed Jaafer Hendi Dr.Haider Mohsen
Dr.Talal Hadi

MacLeod's clinical examination; sec.1 ;part2 history taking and general examination;
page5-30
Davidson's Principles and Practice of Medicine.
For more detailed ruction, any question, cases need help please post to the group of session
Aim:
1. You should use the learned communication
skills in taking a medical history from a real
patient.

2. You have to use an open style of interview and

avoid a closed, medically focused questions.
Traditional Medical History Content

• Identity LO1
• Chief complaint(presenting symptom). LO2
• History Of present illness. LO3
• Systems review. LO4
• Past medical &Surgical history. LO5
• Drug history. LO6
• Family history. LO7
• Social history. LO8
 LO1
Identity (Demographic Data)

• Name
• Age
• Gender
• Race
• Marital status
• Occupation
• Religion
 LO2
Chief Complaint
(Presenting Symptom (ps))

• It is the primary symptom that brought

the patient to the hospital and it’s
duration.
•It should be recorded in patient own
words.

Ex. Pain, fever, vomiting .

 History of Present Illness: LO3
The most important part of medical history.
❖ It is the analysis of the chief complaint and any
associated symptom to understand the full story of
the illness.
❖ Both physician &patient must work together to
develop accurate and useful understanding of the
illness.
History of present illness LO3
Any complaint has 7 core dimensions: SQITARS

Ex. Pain:
▪ Site & radiation.
▪ Quality :sharp , burning, colicky.
▪ Intensity (severity).
▪ Timing: onset , duration.
▪ Aggravating factors.
▪ Relieving factors.
▪ Secondary symptom.
 LO4
Systems Review
ask about each system of the body .
Central nervous system: headache , loss of consciousness,
fit or abnormal movement.
Cardiovascular system: chest pain, palpitation, cyanosis.
Respiratory System: cough, shortness of breath, sputum.
Gastrointestinal system : nausea ,vomiting, diarrhea.
Genitourinary System: dysuria, voiding problem,
hematuria.
Musculoskeletal system : pain, swelling, stiffness.

• Discover further symptoms.

• Find information related to ps.
• Identify unrelated problem that require
change in the management.
 LO5
Past Medical & Surgical History
We must ask about:
• Current and previous medical disease:
diabetes(DM).
hypertension(HT).
ischemic heart disease(IHD).
bleeding tendency.
asthma

• Hospitalization (cause , duration).

• Previous surgery , it’s indication &complication.
• Blood transfusion.
 LO6
Drug History
Medication prescribed.
over the counter.
• type.
• dose.
• frequency.
• duration.
• route of administration (oral, IV, IM, SC).
• drug allergy (penicillin allergy).
 LO7
Family History
It focuses on the health problems of the patient’s
closest relatives.

• Chronic disease in families(DM, HT, heart disease).

• Genetic disease : sickle cell anemia , hemophilia.
• Cause of death in parents and siblings.
• Any cancer in family .
 LO8
Social History
• social habits(alcoholism, smoking)
• job properties.
• home condition.
• financial issues.
• hobbies.
• travel history.

Give information about:

❑ Effect of disease on pt. life & severity (prevent pt. from going to work).
❑ Impact on management (Living environment can affect management).
❑ Risk factors(smoking ,alcohol, occupation, inactivity , hobbies )
We have to remember that tow third of
diagnosis can still be made by the history
alone despite the technological innovations
of modern medicine.
Internal medicine propaedeutic , medical history taking by Dr. Szathmari Miklos;feb.2018

Thanks