Introduction to medicine and history taking

HISTORY TAKING 4\10\2012 Dr. Monem Alshok
Department of Medicine
Introduction and Describing Aim &Objectives
Chief complaint
History of present illness
Past medical history
Systemic enquiry
Family history
Drug history Social history
In Female Obstetric , Gynaecologic & Menstrual H
Introduction
In Clinical Medicine Be or Not to be :
A : Attentive B : Be a Good Listener C : Confident , Courtesy & Respect
D : Dispassionate E : Eye contact ,At ease( Comfort ) , Empathy F : Friendly
G : Guider to the patients , Genuinenessed : Be yourself Know your limit Express your feeling while staying within the bounds of professional relationships Show your true interest to the patients
H : Honest I : Interruption must be avoided J : Jargon Languages & terms avoided K : Knowledgeable L : Leading questions avoid
Be SOLER S : Sit square to the patient O : Open to the patient L : Lean in toward the patient E : Eye contact Listening Empathy Gather Objective Data
Ability to understand the patient R : Relax
Importance of History Taking :Obtaining an accurate history is the critical first step in determining the etiology of a patient s problem.
( A large percentage of the time 70%), you will actually be able make a diagnosis based on the history alone.
How to take a history? The sense of what constitutes important data will grow exponentially in future as you learn about the pathophysiology of disease You are already in possession of the tools that will enable you to obtain a good history. An ability to listen and ask common-sense questions that help define the nature of a particular problem. A vast and sophisticated fund of knowledge not needed to successfully interview a patient.
General Approach
Introduce yourself. Note – never forget patient names Creat patient appropriately in a friendly relaxed way.Confidentiality and respect patient privacy.
Taking the history & Recording:
Always record personal details: name,age, address, sex, ethnicity, occupation, religion, marital status. Record date of examination
CHIEF COMPLAINT Complaints that cause the patient to seek medical advice or to visit his or her doctor its duration must be recorded in the patient’s own words The main reason push the pt. to seek for visiting a physician or for help .Usually a single symptoms, occasionally more than one complaints eg: chest pain, palpitation, shortness of breath, ankle swelling etc …The patient describe the problem in their own words. It should be recorded in pt’s own words.
What brings your here? How can I help you? What seems to be the problem?
Chief Complaint (CC) Short/specific in one clear sentence communicating present/major problem/issue. Timing – fever for last two weeks or since Monday Recurrent –recurring episode of abdominal pain/cough .Any major disease important with PC e.g. DM, asthma, HT, pregnancy, IHD: Note: CC should be put in patient language.
History of Present Illness : Elaborate on the chief complaint in detail
Ask relevant associated symptoms
Have differential diagnosis in mind
Lead the conversation and thoughts Decide and weight the importance of minor complaints
In details of present problem with- time of onset/ mode of evolution/ any investigation; treatment &outcome/any associated +’ve or -’ve symptoms.Relevant or irrelevant
Sequential presentation: Always relay story in days before admission e.g. 1 week before the admission, the patient fell while gardening and cut his foot with a stone. Narrate in details – By that evening, the foot became swollen and patient was unable to walk. Next day patient attended Merjan hospital and they gave him some oral antibiotics. He doesn’t know the name. There is no effect on his condition and two days prior to admission, the foot continued to swell and started to discharge pus. There is high fever and rigors with nausea and vomiting
If patient has more than one symptom, like chest pain, swollen legs and vomiting, take each symptom individually and follow it through fully mentioning significant negatives as well. e.g the pain was central crushing pain radiating to left jaw while mowing the lawn. It lasted for less than 5 minutes and was relieved by taking rest. No associated symptoms with pain/never had this pain before/no relation with food/he is Known smoker,diabetic & father died of heart attack at age of 45 .Avoid medical terminology and make use of a descriptive language that is familiar to them
• Ask OPQRST for each symptom e.g. Pain (OPQRST)
• Onset of disease Position/site Quality, nature, character – burning sharp, stabbing, crushing; also explain depth of pain – superficial or deep.
Relationship to anything or other bodily function/position.
Radiation: where moved to
Relieving or aggravating factors – any activities or position
Severity – how it affects daily work/physical activities. Wakes him up at night, cannot sleep/do any work.
Timing – mode of onset (abrupt or gradual), progression (continuous or intermittent – if intermittent ask frequency and nature.)
Treatment received or/and outcome
Are there any associated symptoms? Check with SR.