CLINICAL HISTORY TAKING

Nashad Mohamed Osman

Why history taking?
 Why history taking?
• Diagnose the pt
• Design appropriate scheme of
management
• There are two main steps to making a diagnosis:

 To establish the clinical features by history and

examination

 To interpret the clinical database in terms of

disease and possible aetiological factors

• Identification of patient – very

important.

• Establish Raport.
 Principles of history taking
• Identification of the patient
• To have adequate information on the presenting
complaint
• Past history: Medical and Surgical
• Medication
 Classification of Pain
• Site
• Radiation
• Character
• Severity
• Time course
• Aggravating factors
• Relieving factors
• Associated symptoms
 History Taking Format:

 Identification:

• Name

• Age

• Tribe

• Religion

• Residence

• Next of kin
 Identification cont.
• Occupation
• Date of admission:
• Education level:
• Point of admission
• Nearest health unit:
• I.P number
• Marital status:
• Referral status
 Presenting complaint (PC) and Duration:

 History of Presenting complaint:

• presenting complaint, duration of presenting

complaint, severity
complications,associations,aetiology or possible
risk factors, interventions so far done in form of
treatment and investigations.
 Review of other systems:

 Cardiovascular system
• Chest pain
• Easy fatiguability
• Palpitation
• Ankle swelling
• Orthopnea
• Nocturnal dyspnea
• Shortness of breath
 Review of other systems
 Respiratory system
• Chest pain
• Shortness of breath
• Cough with or without sputum
• Haemoptysis
 Review of other systems:

 Gastrointestinal
• Abdominal pain
• Dyspepsia
• Dysphagia
• Nausea and/or vomiting
• Anorexia
• Weight loss or gain
• Diarrhoea or constipation
• Rectal bleeding
• Jaundice
 Genitourinary

• Abnormal par vaginal discharge

• PV bleeding

• Genital sores or ulcers

• Haematuria

• Nocturia

• Increased urinary Frequency

• Dysuria
• Incontinence
 Locomotor

• Joint pain

• Muscle pain

• Limb swelling

• Change in mobility

• Joint stiffness
 Neurological • Paraesthesia
• Seizures • Weakness
• Collapse or blackouts • Wasting
• Dizziness and loss of • Spasms and involuntary
balance movements
• Vision • Pain in limbs and back
• Transient loss of function • Headache
(movement, speech, sight) • Hearing loss
 Past medical history:

• Known history of chronic illnesses like

hypertension, Diabetes mellitus, Asthma,sickle
cell disease,epilepsy,liver disease, kidney
disease, cardiac failure, HIV Status etc,
• Medication history
• Allergies
 Past surgical history
 Past surgical history:
• General surgical procedures
• Blood transfusion.
• pelvic fractures
 Family History
• Number of sibling

• Order in the family

• parents alive or dead,

• causes of death in first degree relatives

• Any chronic disease that run in the family?

• Any familial cancers, cancer of colon, prostate, Breast

cancer?
• Any family member who faced similar health problem.
 Social history:

• Marital status

• occupation and occupation of husband( source of

income)

• Health risks: alcohol intake, cigarette smoking

• Nature of shelter, source of water

 Summary: Brief

• Initials of patient,age, any known chronic illness

• P.C and its duration key associations

• Complications and possible aetiology

• Interventions so far

• Any other significant aspect from the rest of the history

 Provisional Diagnosis:

• Differential diagnosis:
THANK YOU.