History taking -Department of Internal Medicine- College of medicine/ Babylon University Third year

History taking
Department of Internal Medicine
College of medicine/ Babylon University
Third year
At the beginning, the student need to gather the following information
Patient’s name/ age/ sex/ religion/ occupation/ home address/ marital status/ date of admission/ date of history taking
Chief complaint and duration: please mention here the main problem(s) that made the patient seeks the medical advice and the duration of this(ese) compliant(s). It is preferable to mention one chief complaint.
Record patient’s words and don’t mention medical jargons for example say shortness of breath and not dyspnea, loose bowel or frequent bowel motions rather than diarrhea.
History of presenting illness: In this section, the student needs to tell the story of patient’s compliant in a way that helps to narrow the differential diagnosis of the underlying cause.
For example, when the chief complaint is pain (anywhere) the history of presenting illness should answer the following questions
SOCRATESSite, Onset (sudden or gradual), Character, Radiation, Associated symptoms (like nausea and vomiting), Timing/ Duration and frequency, Exacerbating and relieving factors, Severity.
If the chief complaint (the pain) is related to the cardiovascular system for example, all questions of systemic review that are related to that system should be answered here.
The student need to mention any investigation/ procedure(s) has been done and treatment prescribed to the patient during this hospital admission. The change in patient’s condition whether for better or worse need to be explored and documented.