2.What's the Importance of History Taking.pptx

History taking - case taking

1. Case Taking Art Of History Taking Dr. Karamchand MD (Hom)

2. ? Importance of History Taking 80% of Diagnosis can made on a good History Taking 20% - P/E + Investigation It also helps to create a good Dr. <- >Patient Relation Be a Good Listener

3. For that…. You should be a Good Listener You should have the patience & Note down all the points in patients own language ( Not by Medical Terminology)

4. Prerequisite of General Examinations It should be in a comfortable position / Situation. Assure your patient about the significance of the examination It has to be done in a Day light , as skin change are better appreciated by a natural light -Avoid Artificial Lights . Dr.Karamchand MD (Hom)

5. History taking H/O Medical significance It should be in chronological order Recent events with most attention Pt should be allowed to narrate-without interruption ? Infliction of voice/Facial expression/ Attitude is imp If needed allow third person/ family member etc. No leading questions…….

6. Particulars Name Age Sex Gender Occupation Religion / Address DOA / DOE /DOD

7. Chief Complaint The complaint /symptoms which has lead the pt to visit a doctor / Hospital . In chronological order. It should not be written in medical terminology/ should be in pt’s own language- with its duration Eg :-Fever- 15 days cough & Dyspnea-10 days ? Any associated Symptoms

8. Chief complaints Analysis of symptoms Eg :- fever, Cough ,Dyspnea…etc. Pain  Site Radiation Severity Timing Occurrence - </> Effect of Trt . Duration – A/c, C/c

9. When did you first begin experiencing symptoms? Have your symptoms been continuous or occasional? How severe are your symptoms? What, if anything, seems to improve your symptoms? What, if anything, appears to worsen your symptoms ?

10. Past History/ illness similar illness in the past ? Any h/o C/illness- DM, HPTN, TB, COPD Ask only relevant questions Since infancy ?? Measels , Rh fever, TB Quinsy  ? HAV  ? Childhood Illness Adult Medical illness

11. Personal History Food habits- veg/ nv / Marital status Bowel habits Bladder habits Sleep pattern Appetite etc Any H/o Abuse- IV, Drugs , homosexuality, multiple partners, multiple unprotected intercourse

12. Family H/O Pts Family members Hereditary Disorders-? Any significant history Genetic Disorders DM,HPTN,CAD,TIA, Tb, etc.. Thyroid, Renal, Ca , Arthritis Asthma , Tb, Seizures , Psychiatric, Alcoholism Drug allergies etc Food habits- alcoholism ,

13. Trt . History/ Drug History Any trt is getting for the present illness, What are medicine used by the pt ? Is Pt Is on DM, HPTn medicines

14. Allergy History Any allergy to any kind of food/ medicines/ drugs……

15. Immunisation Status Fully/ partially immunized as per the National Immunization Schedule

16. In FM Pts - Menstrual/OBG history ?Age of onset- Menarche Regularity/irregularity Flow – heavy/Scanty flow Any Dysmenorrhea /not Duration & Quantity of blood loss? H/o Amenorrhea ? PMS? In Meapausal lady-Age of Menopause OBG H/O:-Number of birth ?? MODE OF Delivery- Normal/CS Any compli ? ? Onset of menopause? Perimenapausal bleeding ?endometrial ca? fibroid ?

17. Social/Personal/ Occupational History Physical/Emotional environment Habits, Mental attitude Exact nature of work Domestic + Marital relations Home surroundings

18. Social History Upbringing Domestic life- over crowding Source food/ drinking water Marital status House + surroundings Education- Occupation Finance/ Family support Leisure activities etc.

19. Habits/Hobbies Smoking Drinking – Alcohol Abuse of – Drugs other..

20. Psychological History ?psycho-neurosis , psych-somatic disorders like PUD, hyper thy, B Asthma , U C , IBD etc.. Type of work, sexual relations GAD, Depression ?False perception?