dr_Lord
07-25-2004, 01:44 AM
History Taking
Welcome everyone. In this thread I will try cover the important points in history taking.
First let’s know the main titles in the history (Hx);
1- Patient’s Personal Data.
2- Chief Complain.
3- History of Presenting Illness (HPI).
4- Past Medical History.
5- Medications, Allergies, and Blood Transfusions.
6- Family History.
7- Social History.
8- Systemic Review.
Now we can discuss the details of each one.
1- Patient’s Personal Data: This includes patient’s Name, Age, Sex, Nationality, Date of admission, and the way of admission (through ER or OPD).
2- Chief Complain: Ask the patient about the specific reason/reasons of admission. Why was he admitted to the hospital this time, let’s say for example (Doctor, I felt some pain in my chest 3 hours ago which made me to come to the ER!!) so we write Chest Pain as his Chief Complain.
3- History of Presenting Illness: Now after knowing the Chief Complain, take more information and details about it/them. If the patient complains of more than one thing, you have to discuss them separately. Ask the patient the following questions.
A- Onset: when did it happen to you sir?! Try to take exact timing.
B- Duration: How long did take when happened?! Was it continuous of intermittent?!
C- Site: Where do you feel it of notice it?!
D- Radiation: Does it go to any other sites?! Can you feel it in other sites?!
E- Character: Can you describe it for me sir?! How does it feel like??!
F- Severity: How sever was it?! Does it prevent you from sleeping or work normally?!
G- Progression: Does it improve or getting worse during the last few days?! or since it occurred to you.
H- Aggravating factor: Is their any thing that aggravates it?!
I- Relieving factor: Is their any thing that relieve it?!
J- Associated symptoms: When it occurred, was there any thing else occurred to you?!
N.B. Let the patient answers you by his own words first, and explains to him what ever he doesn’t understands.
4- Past Medical History: Ask about any past illness (e.g. Asthma, T.B?) and ask about PREVIOS ADMISIONS to hospitals and why and for how long did he stay in it.
5- Medications, Allergies, and Blood Transfusions: Ask the patient if he is taking any medications (especially if he has chronic illness). Name the medications and their type, how many times/day does he take them, and the amount. Ask if the patient has any allergy to kind of drug or food. Ask also about previous blood transfusion (when, why, how many units).
6- Family History: Ask if any member of his family has a history of disease (e.g. T.B) or same complain.
7- Social History: Well, it might be little embarrassing for you at the beginning and difficult to ask, but you MUST ask in a polite way to NEVER embarrasses the patient. Ask about the followings: Marital, Children, Smoking, Alcohol, Education, Occupation, Travel … etc.
8- Systemic review: ask about each system separately e.g. CNS, CVS, Renal …etc.
Remember:
-Always be polite with the patient and never embarrass him.
-Be systemic in the history order, just follow the points I’ve mentioned already so that you will not get confused and mix up the informations in your mind.
-Be confident and don’t be shy, and always remember that there are residents and specialists around you, If you didn’t understand something go and ask them in a polite way and they won’t refuse helping you.
Done, with my best regards;
Dr.Lord
Welcome everyone. In this thread I will try cover the important points in history taking.
First let’s know the main titles in the history (Hx);
1- Patient’s Personal Data.
2- Chief Complain.
3- History of Presenting Illness (HPI).
4- Past Medical History.
5- Medications, Allergies, and Blood Transfusions.
6- Family History.
7- Social History.
8- Systemic Review.
Now we can discuss the details of each one.
1- Patient’s Personal Data: This includes patient’s Name, Age, Sex, Nationality, Date of admission, and the way of admission (through ER or OPD).
2- Chief Complain: Ask the patient about the specific reason/reasons of admission. Why was he admitted to the hospital this time, let’s say for example (Doctor, I felt some pain in my chest 3 hours ago which made me to come to the ER!!) so we write Chest Pain as his Chief Complain.
3- History of Presenting Illness: Now after knowing the Chief Complain, take more information and details about it/them. If the patient complains of more than one thing, you have to discuss them separately. Ask the patient the following questions.
A- Onset: when did it happen to you sir?! Try to take exact timing.
B- Duration: How long did take when happened?! Was it continuous of intermittent?!
C- Site: Where do you feel it of notice it?!
D- Radiation: Does it go to any other sites?! Can you feel it in other sites?!
E- Character: Can you describe it for me sir?! How does it feel like??!
F- Severity: How sever was it?! Does it prevent you from sleeping or work normally?!
G- Progression: Does it improve or getting worse during the last few days?! or since it occurred to you.
H- Aggravating factor: Is their any thing that aggravates it?!
I- Relieving factor: Is their any thing that relieve it?!
J- Associated symptoms: When it occurred, was there any thing else occurred to you?!
N.B. Let the patient answers you by his own words first, and explains to him what ever he doesn’t understands.
4- Past Medical History: Ask about any past illness (e.g. Asthma, T.B?) and ask about PREVIOS ADMISIONS to hospitals and why and for how long did he stay in it.
5- Medications, Allergies, and Blood Transfusions: Ask the patient if he is taking any medications (especially if he has chronic illness). Name the medications and their type, how many times/day does he take them, and the amount. Ask if the patient has any allergy to kind of drug or food. Ask also about previous blood transfusion (when, why, how many units).
6- Family History: Ask if any member of his family has a history of disease (e.g. T.B) or same complain.
7- Social History: Well, it might be little embarrassing for you at the beginning and difficult to ask, but you MUST ask in a polite way to NEVER embarrasses the patient. Ask about the followings: Marital, Children, Smoking, Alcohol, Education, Occupation, Travel … etc.
8- Systemic review: ask about each system separately e.g. CNS, CVS, Renal …etc.
Remember:
-Always be polite with the patient and never embarrass him.
-Be systemic in the history order, just follow the points I’ve mentioned already so that you will not get confused and mix up the informations in your mind.
-Be confident and don’t be shy, and always remember that there are residents and specialists around you, If you didn’t understand something go and ask them in a polite way and they won’t refuse helping you.
Done, with my best regards;
Dr.Lord