PLASMA

UNIVERSITY
GURIEL-GALGADUD

• SUBJECT: HISTORY TAKING AND PHYSICAL EXAMINATION

• LECTURER : Dr Abdulkadir Ali Abdi Shire

• EMERGENCY DOCTOR AT FAYOCARE HOSPITAL

HISTORY TAKING AND PHYSICAL EXAMINATION

• The History
• Welcome the patient - ensure comfort and privacy
• Know and use the patient's name - introduce and
identify yourself
• Set the Agenda for the questioning
HISTORY TAKING AND PHYSICAL EXAMINATION

• Use open-ended questions initially

• Negotiate a list of all issues - avoid excessive
detail initially
• Chief complaint(s) and other concerns
• Specific requests (i.e. medication refills)
• Clarify the patient's expectations for this visit
- ask the patient "Why now?"
WAYS TO REMEMBER
• SUBJECTIVE DATA: WORDS THAT PT TELLS YOU
• OBJECTIVE DATA: FEELINGS THAT NURSE OR DR SEE
• SYMPTOM: WHAT PT TELLS U (EXAMPLE: I FEEL NECK PAIN)
• SING : WHAT PHYCIAN SEE ON EXAM
 Components of the History

•Chief complaint
•History of Present Illness
•Past Medical History
•Past Surgical History
•Allergies
•Medications
Social History
•Family History
•MENSES HISTORY
•Review of Systems
Chief Complaint

• This is why the patient is here in the emergency

room or the office
• Examples
• Shortness of breath
• Chest pain
• Nausea or vomiting
History of Present Illness

• This is the detailed reason why the patient is

here
• It is the why, when and where, etc
• Use the SOCRATES approach to cover all aspects of
information
• Site
• Onset
• Character
• Radiation (if pain or discomfort)
• Alleviating factors
• Timing
• Exacerbating factors
• Severity
Past Medical History

• These are the medical conditions that the patient

has chronically and that they see a doctor for.
• Examples
• Hypertension, GERD, Depression, Congestive heart
failure, hyperlipidemia, Diabetes, Asthma,
Allergies, Thyroid problems, etc
Past Surgical History

• These are any previous operations that the

patient may have had
• Make sure to put how old the patient was when
they occurred
• Include even those that occurred in childhood
• Examples
• Tonsillectomy, Hysterectomy, Appendectomy,
Hernias, Cholecystectomy
• Any history of blood trannsfusion
Medications

• Include all meds the patient is oneven over the

counter meds and herbals
• Try to include the dosages if the patient knows
them
• Include how often the patient takes them
Allergies

• Make sure to ask about medication allergies and

the reaction that the patient has to them
• Ask about latex, food and seasonal allergies
Social History

• Things to include
• Occupation
• Marriage status
• Tobacco usehow much and for how long
• Alcohol use
• Illicit drug use
• Immunization status
• If pertinent, sexually transmitted disease history
Family History

• Ask if the patients parents, grandparents,

siblings or other family members had any major
medical conditions
• Examples
• Heart disease, heart attacks, hypertension,
hyperlipidemia, diabetes, sickle cell disease
Menstrual history
• For women, a menstrual history should be obtained; it is particularly
relevant for a patient with abdominal pain, a suspected endocrine
disease or genitourinary symptoms
• Write down the date of the last menstrual period
• Ask about the age at which menstruation began
• if the periods are regular, or whether menopause has occurred.
Review of Systems

• The review of systems is just that, a series of

questions grouped by organ system including
• General/Constitutional
• Skin/Breast
• Eyes/Ears/Nose/Mouth/Throat
• Cardiovascular
• Respiratory
• Gastrointestinal
• Genitourinary
• Musculoskeletal
• Neurologic/Psychiatric
• Allergic/Immunologic/Lymphatic/Endocrine