History taking

Semester 10
 ILOs
1.1.8. Take and record a structured, patient centered history from
patients presented with blood disorders (thrombocytopenia,
anemia, leukocytosis)
Take and record a structured, patient centered history from .1.1.9
.patients with malignant diseases
1.2.1. Apply the physician patient relationship standards with
considering the social and behavioural backgrounds.
1.3.1. Assess the conscious state of the patient.
2.2.1.recognize and understand the effect of social, economic,
cultural, psychological state on interaction between the patients and
rheumatological and autoimmune ,malignant and hematological
problems , emergent health situations
2.4.2.Recognize risk factor for hematological disorder
(lymphomas,acute and chronic leukemia), malignant diseases.
3.4.1. Communicate effectively with patients or their guardians
from all social/cultural backgrounds without prejudice or bias
towards their mannerisms, beliefs, language, and lifestyle.
5.5.1 Utilize the health records and the electronic medical
records in communicating efficiently with other members of the
health care team.
5.9.1. Use the patients digital clinical record in recording patient
data and retrieve the information from the archive
5.9.2. Access information sources and use the information in
relation to care, health promotion ,advise and information to
patient in emergency surgery and critical care medicine disease.
INTRODUCTION OF HEMATOLOGY/ONCOLOGY
SYMPTOMS
1- Manifestations of Anemia
2- Manifestations of Leucopenia
3- Bleeding
4- Swelling/Organomegaly
5- Constitutional manifestations
6- Transfusion needs
 Anemia
( qualitative low COP symptoms)

• Headache
• Fatigue
• Lassitude
• Lack of concentration
• Blurring of vision/tinnitus
• Palpitations
• Shortness of breath
• Cramps (intermittent
• claudication)
• oliguria
 Leucopenia
• Recurrent / unusual infections
• Recurrent fever/ pyrexia of unknown origin
 Bleeding
• Orificial (bleeding per nose, bleeding per gums,
heamatemesis, hemoptosis, hematuria, bleeding per
rectum, vaginal bleeding)
• Subcutaneous bleeding: petechiae, purpura,
ecchymosis, hematomas
• Deep ( internal hemorrahge/bleeding):
haemoarthrosis, deep intramuscular
hematomas, bleeding inside a cavity.
 Swelling/organomegaly
Symptoms are according to site
 Fullness/heaviness/dragging pain
 AbdominaL Enlargement
 Pressure manifestations for example:
• L.Ns  Mediastinal syndrome
• Pelvic mass  Conistipation
 Conistitutional/B-symptoms
• Low grade fever
• Drenching sweating
• Weight loss (more than 10% in less than 6
months without diet)
• Bone aches
• Pruritis
 Transfusion needs
• Type of component
• Cause of transfusion
• Frequency of transfusion
• Any complications
HISTORY TAKING
 Items of History taking
• Personal history
• Chief complaint
• Present history
• Past history
• Family history
 Personal history
Break the ice

• Name : familiarity with the patient

• Age
Certain risk
• Gender or prognostic
• Occupation factors in
some
• Residency diseases
• Marital status/off-sprins (number and age):
Fertility status/may be benefial in therapy plan
• Special habits (smoking/ alcohol/addictive drugs)
 By the end of personal history
we can
Assess the conscious state, IQ, co-operative
status of the patient.
Recognize and understand the social, economic,
cultural, psychological state of the patient
 Chief complaint
• What made the patient to seek medical
consultation:

 In patient own words

 Chronological orders
 Specify duration
Present hx
Past hx
 Present history

1- Analysis of the complaint

2- Symptoms of same system
3- Symptoms of other systems
4- Journey of the patient
5- Medical diseases
6- Any daily medication (aspirin,
antiepileptics/antipsychotics…….etc)
 1- Analysis of the complaint

• Onset:
Sudden ....within hours
Acute....within days
Subacute days to weeks
Chronic......weeks to month
Incidious: unclear onset
• Course: (progressive/regressive/stationary/remission
and exacerbation)
• Duration: (for example: long term duration may be
benign).
Any sp. Questions on the main complaint:
• Anemia
(diet, drugs, bleeding, yellowish coloration of skin/sclera,
bowel habit change, urine/stool color change)
• Bleeding
(Site, ?? with trauma or not, Amount/color)
• Swelling
Site, size, painful or not, skin on top, ??discharge
(sinus/fistula), affection of the surroundings i.e. affect
swallowing/causing edema
 2- Symptoms of same system

• Ask about the other symptoms

 3- Review (Symptoms) of other systems
(ROS)
• Cardiac
• Chest
• GIT
• CNS
• Genitourinary
 4- Journey
• Time of seeking medical advice
• Any requested investigations (laboratory, or
radiological)
• ask about BM if suspect leukemia
• ask about biopsy
• Any prescribed medications
• ??Improvement/deterioration of the condition
• Cause of referral
5-History of previous illness (HOPI) & daily
medications

For example: DM, HTN, cardiac, chronic renal

disease, chronic hepatic disease
 Past history
 Medical:  Surgical: Any previous
• Significant previous surgical intervention
illness/infection
• Medications/vaccinations
• Allergies
• Travel abroad
• Transfusion
• Hospitalization
 Family history

• Consanguinity
• Similar conditions
The recording system