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1. Mr.Rami Wisa BDS,MFD RCSI ,MD in OMFS History Taking :-

2. Components of patient’s history 1. PERSONAL DATA 2. PRESENTING COMPLAINS C/O 3. HISTORY OF PRESENTING ILLNESS (HPI ) 4. SYSTEMTIC REVIEW 5 . PAST MEDICAL HISTORY (PMH ) 6. FAMILY HISTORY 7. DRUG HISTORY 8. SOCIAL HISTORY

3. Introduction:- To get an appropriate diagnosis, systematic approach is needed, following the steps below: A. History taking. B. Physical examination. C. Investigations.

4. 1) History taking More than 80 % of the diagnosis can only be obtained by taking the patient’s proper history. By Taking time to ask the patient the important questions and analyzing them, this will not only help in reaching the appropriate differential diagnosis, but also make physical examination and ordering a proper investigation more easily. To take a complete history, you need to build a good communication and relationship with your patient and that can be achieved by mastering the following skills: 1- Active listening and speaking. 2- Using appropriate body language. 3- Asking smart questions and giving the patient

5. The art of history talking: To portray a perfect History the doctor should know: 1-How to take a complete history from the patient. 2- Ho w to write the history down in the file or patient’s document. 3- And how to present it to the seniors or colleges. (So let us sit with our patients and talk.)

6. How to take a complete history from the patient: -The history should be taken in the patient’s language. You are allowed to use all the communication skills and the techniques listed above to connect with your patient and stimulate him /her to talk. -Always remember language is not a barrier, if you do not speak the same language as the patient dose you can use body language (signs and gestures) or even a translator.

7. How to write the history down in the file or patient’s document: History can be written in any language but English language by far the most universal one. -Each step of the history as we will see later, has it is own different way of writing. How to present the history to the seniors or colleges: -Putting your own touches in presenting any history, will give the case that special unique character. -Telling the patient’s problem in a story style with changing the voice tone and emotion will always make the audients want to know more.

8. The components of the history 1) Personal data. 2) Presenting complain. 3) History of presenting illness. 4) Systematic review. 5) Past medical history. 6) Family history. 7) Drug history. 8) Social history. 9) The summary.

9. PERSONAL DATA Date Name Age Gender Residence/ Origin Occupation Nationality/Tribe Marital status Contact number

10. Name:- I. Good communication. II. Identification. III. Documentation. IV. Combine names “two names for one person”.

11. Age:- I. Certain diseases related to specific age group. II. Better to ask than to assume a number according to the appearance of the patient, because some people don’t look like their real age e.g. Makeup, plastic surgery, or Botux injection.

12. Gender:- I. Unisex names. II. Inherited genetic problems.

13. Residence/origin :- I. Environment that the patient lives in, e.g. shortness of breathing living near a chemical factory. II. Any endemic diseases in his/her current or origin residence. III. A clue about the patient economic status “high or low class neighborhood” “is the patient renting or owning”

14. Occupation :- I. Job related illnesses. II. Level of education. III. Economic status.

15. Tribe/race/ Ethnicity/ Nationality :- Genetic background and any family illness e.g. Sicklecell anemia

16. Marital status :- I. Sexual transmitted diseases

17. How to present the personal data: Usually it is preferably to be presented in a storyline manner. For example: My patient’s name is ……………….he is ….........…years old, lives in ………. originally from …….........……. He works as …….......….. at…….......…. From ….......…. tribe, he is single.

18. 2. PRESENTING COMPLAINTS C/O 1- What complaint brought the patient to seek medical advice? (Symptoms and duration) 2-We ask about the duration because usually the patients tell us what bother them the most, and they did not putthe symptoms in order of their happening. 3-Be careful of old symptoms, they should be listed under past medical history. 4- If diabetic patient or hypertensive or have any chronic illness it is better to be mentioned here to help reaching an accurate diagnosis. The details about the chronic illness should be mentioned in the past medical history.

19. 3. HISTORY OF PRESENTING ILLNESS (HPI): 1- Onset 2- Duration 3- Site 4- Frequency 5- Type and character 6- Radiation 7-Severity 8- Aggravating and relievi n g factors. 9- Associated symptoms

20. 4. SYSTEMTIC REVIEW -Ask about all the systems except the system involve. - The Purpose: I. To find out if the other systems affected with the current problem. II. Some patients neglect or forget to mention the other systems (other than the system involve) thinking these symptoms have no relation with their current problem.

21. -Cardiopulmonary system (CVS): Cough, sputum, hemoptysis (coughing of blood), shortness of breath ( Dyspnea ), chest pain, palpitations, wheeze, syncopal attack & oedema . -Gastrointestinal system (GIT): Abdominal pain, nausea, vomiting, hematemesis (vomiting of blood), diarrhea, constipation, heart burn, difficulty in swallowing, indigestion, abdominal distention, gasses and yellow discoloration of the sclera. -Central nervous system (CNS): -Headache, convulsions, weakness, paralysis, projectile vomiting, Visual problems, photophobia Hearing disturbances, Dizziness, vertigo, numbness, sphincter disturbance, and depression.

22. - Urogenital system: -Urine (color e.g. hematuria , amount, frequency, associated with pain, burning micturition ), urgency, hesitancy, burning Micturition , Incontinence, dysuria , and nocturia . -Ask about the menstrual cycle (duration, frequency, amount, associated with symptoms like dysmenorrhoea ). -Vaginal discharge (color consistency and itching). -Musculoskeletal system: -Fatigability, joints, muscular pain and stiffness, skin rash and itching.

23. 5. PAST MEDICAL HISTORY (PMH):- Past medical history of chronic illness. For example: -Do you have diabetes mellitus? -If the answer is YES the questions will be: 1-For how long? 2-What type of diabetes you have? 3-Are you on regular follow up? 4 -Name of the drug you are taking? 5-Amount and time of the dose?

24. Past medical history of hospitalization: -Have you ever been admitted to a hospital before? -If the answer is yes: 1- How many times? 2- The time and duration of each admission? 3- What was the diagnosis? 4- Did you remember the medication you took? 5- What happen after the discharge?

25. Past medical history of blood transfusion :- Have you had a blood transfusion before? If the answer is yes? 1- How many times? 2-What was the reason for the transfusion? 3- Did you experience any complication form this transfusion?

26. 6. FAMILY HISTORY:- Family history of similar condition Family history of chronic ill- ness Family History of Sudden death Family history of congenital diseases

27. 7. DRUG HISTORY:- Chronic medication Allergy to any medication Current medication :- -Interaction if you want to give a new drug. - May be the current drug has something to do with the current condition.

28. 8. SOCIAL HISTORY Two main questions should be asked, housing condition and habits. At the end you should determine the SOCIOECONOMIC STATUS of the patient, high-moderate- or low.

29. Do you smoke? If the answer is YES; - What type (Cigarettes, Cigars & Shisha )? 1- For how long? 2- How many cigarettes per day? - Do you consume alcohol? If the answer is YES: 1- What type? Local or a brand? 2- How many classes per day? 3- For how long? Snuff dipper ????