Principles of history taking

Reviewing the Chart: 
The medical chart give you valuable information about past diagnosis and treatment  You should look at the identifying data (age, gender, address, marital status, health insurance, the medication list, the documentation of allergies)

Clinician¶s Behaviors 
As you observe the patient throught the interview, the patient will be watching you  You should be sensitive to those messages and manage them as well as you can  Posture, gesture, eye contact, and words can express interest, attention, acceptance, and understanding  The skilled interviewer seems calm and unhurried, even when time is limited

Clinician¶s Appearance
Cleanliness, neatness and a name tag are reassuring to the patient. Remember that you want the patient to trust you

Note taking You need to write down much of what you learn in a health history The Enviroment Make the setting as private as possible .

clarify your role.Learning about the Patient¶s iIlness Greeting the Patient  Greet the patient and introduce yourself by name  If this is the first contact. ask the permission of the patient to conduct the interview in front of them . such as stating your status as a student and explaining your relation to the patient¶s care  When other individuals are present.

The Patient¶s Comfort Be alert to the patient¶s comfort .

maritual status and occupation  Source of history: such as patient. friend. family. medical record  Chief complaints .Comprehensive history  Data and time of history: the date is important  Identifying data: including age. officer. consultant. gender.

chicken pox. rubella. mumps. rheumatic fever. polio . whooping cough.Comprehensive history  Present illnes  Current medication: including dose and frequency of use  Allergies  Past history  Childhood illnesses: such as measles.

Diabetes mellitus 2. HIV . Hepatitis 4.Comprehensive history  Adult illnesses: Medical 1. Hypertension 3. Asthma 5.

diagnosis. at-risk atpractises Psychiatric: include dates. outcome Obstetric/ Gynecologic: inculde obstetric history.Comprehensive history  Adult illnesses: Surgical: include dates. number and gender of partners. menstruation history. birth control. treatment . indication. hospitalisations.

amount and duration of use)  Drugs (type used. amount and duration of use)  Alcohol (type used. amount and duration of use) .Current health status Tobacco (type used.

8. Exercise and diet Immunisations: Tetanus Pertussis Diphteria Polio Measles Rubella Mumps Influenza Hepatitis B . 3. 5. 4. 2. 6.Current health status   1. 9. 7.

spouse. siblings. or age and couse of death of each immediate family members (parents. and children)  Date of grandparents and grandchildren may also be useful .Family history Age and health.

Family history       Diabetes mellitus Heart disease Hypercholeterolemia High blood pressure Stroke Kidney diseases .

Family history       Arthritis Anemia Allergies Asthma Headaches Mental illness .

Family history     Tuberculosis Cancer Drugs Epilepsy .

Personal and Social History  Occupation and education  Home situation  Daily life  Leisure activites/hobbies .

Factors that have aggrevated or relieved them .Present illness The principal symptoms should be discribed in terms of: 1. Quality 3. Location 2. Timing 5. Quantity and severity 4.

Review of systems General:  Weight. recent weight change  Weakness  Fatique  Fever .

 lumps.  itching.  sores.  dryness.  color change  Hair and nails changes .Review of systems Skin:  Rashes.

nasal sinuses: stuffiness. hay fever. double vision. glasses. Eyes: redness. glaucoma. flashing lights.Review of systems  Head: headache. vertigo Ears:  Nose an sinuses: frequent cold. spots. dizziness Head:  Eyes: vision. cataracta  Ears: hearing. pain. sinus trouble . dryness. head injury. contact lenses.

sore tonque. Äswollen glands´. pain and discomfort Breast:  Respiratory: cough. bleeding throut: gums.goiter pain Neck:  Breast: lumps. sputum (color quantity) Respiratory: hemoptysis.Review of systems  Mouth and throut: condition of teeth. tuberculosis. emphysema. pneumonia. wheezing. dry mouth. dyspnea. asthma. frequnt sore throats. bronchitis. hourseness  Neck: lumps. gums. .

 high blood pressure.Review of systems Cardiac: Cardiac:  heart trouble. orthopnoe.  heart murmurs. paroxysmal nocturnal dyspnoe. dyspnoe. edema .  chest pain or discomfort.  rheumatic fever.  palpitations.

Review of systems Gastrointestinal: Gastrointestinal:  Trouble swallowing  Heartburn  Appetite  Nausea  Vomiting  Regurgitation  Vomiting of blood .

Review of systems Gastrointestinal: Gastrointestinal: Bowel movements Color and size of stools Change of bowel habits Rectal bleeding Black tarry stools Hemorrhoids Constipation Diarrhea .

Review of systems Gastrointestinal: Abdominal pain Food intolerance Jaundice Liver or gallbladder trouble hepatitis .

Review of systems Urinary:  Frequency of urination  Polyuria  Nocturia  Burning or pain on urination  Hematuria  Urgency  Reduces caliber or force if the urinary stream  Incontinece  stones .

Review of systems Genital: Genital: Female:  Age at menarche  Regularity  Frequency  Duration of periods  Amount of bleeding  Last period .

Review of systems Genital: Femal:  Dysmenorrhea  Premenstrual tension  Age at menopausa  Itching  Sexually transmitted diseases  Number of pregnanycies  Number and type of delivery  Number of abortion .

Review of systems Genital: Male:  Hernias  Testicular pain  Sexually transmitted diseases .

Review of systems Periferla vascular:  Intermitten claudication  Leg cramps  Varicose veins  Past clots in the veins .

weakness  Joint pain  Stiffness  Arthritis  Gout  Backache .Review of systems Musculoskeletal:  Muscle pain.

Seizeres 2.Review of systems Neurologic: 1. Weakness 3. Numness or loss of sensation 5. Tremor . Paralysis 4.

Review of systems Hematologic  Anemia  Easy bruising or bleeding  Past transfusion .

Review of systems Endocrine  Thyroid trouble  Heat or cold intolerance  Excessive sweating  Diabetes  Excessive thirst or hunger  polyuria .

 This is done by using direct questioning  Questionts should proceed from the general to the specific . significant.Establishing Rapport  The initial contact with the patient sets the foundation for the relationship  Good interviewing technique allows patients to recount their own stories spontaneously  You should listen actively and watch for clues to important symptoms. emotions events. and relationships  You can than guide the patient into telling you more about the areas that seem most significant.

 Sometimes patients seem quite unable to describe their symptoms without help  Offer multiple-choice answers´ Is your pain aching. shooting. multipleanswers´ aching. or what? what?  Use lanquage that is undestandable and appropiate to the patient  Establishing the sequence and time course of the patient¶s symptoms is important  You can encourage a chronologic account by such questions as´ What than?´ or ÄWhat happened next?´ than?´ ÄWhat next?´ . burning. sharp. pressing.

leg pain. you should be generating hypotheses about what body systems might be involved by a pathologic process  For example. suggests a problem in the peripheral vascular.Generating and Testing Diagnostic Hypotheses  As you learn about the patient¶s story and the symptoms. or nervous system . musculoskeletal.

How long does it last? How often does it come?  5. 2. reactions. including enviromental factors. How bad is it? severity.  6. When did or does it start? timing. Its timing.1. Its location. 3. personal activities. The setting in which it occurs. What is it like? quality. Its quantity or severity. Its quality.Where is it? Does it radiate? location.     . 4. worse. Factors that make it better or worse. emotional reactions.

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