Clinical Method - Patient history taking procedures

For clinical case history taking methods

1. Presented By
ProfSriramChandraMishra
KayachikitsaDepartment
VYDSAyurvedMahavidyalaya,Khurja
Patient
History taking procedures

2. C. V. 4/12
KNOWLEDGE &WISDOM
→Over80%ofdiagnosesaremadeonhistoryalone,a
further5-10%onexaminationandtheremainderon
investigation.
11/28/20212

3. 11/28/20213
CLINICALMETHOD –
Itisthetermusedtodescribeaproperlyorganizedapproachtothe
patientandtohis/herdisease.
CLINICAL–
Foundedonactualobservationandtreatmentofpatientsasdistinguished
fromdataobtainedbyexperimentationorpathology.

4. 4 11/28/2021
Itistruismsthat“DIAGNOSIS SHOULD PRECEDE TREATMENT WHENEVER
POSSIBLE”,butthewisedoctoralwaysstrivenotsimplytobeadiagnosticianbut
rathersomeonewhoelucidateshumanproblems.(Hutchinson’sclinicalmethod)
C. Su. 20/20
•Forexample,
→anambulanceparamedicwouldtypicallylimithishistorytoimportantdetails,suchasname,historyofpresentingcomplaint,allergies,etc.
→Incontrast,apsychiatrichistoryisfrequentlylengthyandindepth,asmanydetailsaboutthepatient'slifearerelevanttoformulatinga
managementplanforapsychiatricillness.

5. 5 11/28/2021
Butifdiagnosisisnotpossible,thentreataccordingtonatureofthe
disorder,locations,etiologicalfactorsetc.
C. Su. 18/44-47

6. 6 11/28/2021
•TRIVIDHA-DARSAN,SPARSAN,PRASNA(A.H.SU.1/22)(C.CHI.25/22)
APTOPRADESH ,PRATAKSHA ,ANUMAN (C.VI.4/3)
•CHATURVIDHA -APTOPADESH ,PRATAKSHA ,ANUMAN,YUKTI(C.SU.11/17)
•PANCHAVIDHA –NIDAN,PURVARUPA ,RUPA,UPASAYA,SAMPRAPTI (M.N.)
•SADVIDHA–SROTENDRIYA ,TWACHA,NETRA,JIHWA,GHRANA
(PANCHABHI SROTADIBHI)ANDPRASNAPARIKSHA
•ASTAVIDHA –NADI,MUTRA,MALA,JIHWA,SABDA,SPARSA,DRUK,AKRITI(YOGARATNAKAR )
•DASAVIDHA –PRAKRITI,VIKRITI,SARA,SAMHANAN ,
PRAMANA,SATMYA,SATWA,AHARASAKTI,
VYAYAMA SAKTI,VAYAH(Charak)

7. 7 11/28/2021
SYSTEMIC
EXAMINATIONS
GENERAL
EXAMINATIONS
PERSONAL DETAILS
DIAGNOSIS
&
TREATMENT
THE HISTORY
PHYSICAL & MENTAL
EXAMINATIONS
PROVISIONAL
DIAGNOSIS
------------------
INVESTIGATIONS

8. 8 11/28/2021
PRINCIPLESOFCLINICALMETHOD
•Properlyorganizedapproach(NOPROPERSEQUENCE)
Theexperienceddoctorbeginstheconsultationfromthemomentthepatientwalksinto
theroom,thegeneralappearance,dress,attitude,gait,vocabulary,personalityandonly
finishedwhenthepatienthasleft.
•Patient–DoctorRelationship
Vocaltones,bodylanguage,openness,presenceandconcealmentofattitude,maintain
aprofessionalrapport,upholdpatients’dignityandrespecttheirprivacyetcareresponsible
forasatisfactoryestablishmentofPatient–Doctorrelationship.
•Information
Informationregardingillnessshouldalwaysbeobtainedfromthepatienthimself,
wheneverthepatientisinafitstatetocommunicate.Incaseofpatient’sconsciousnessis
disturbedorhe/sheiscriticallyillormentallyinfirm,suchinformationmaybecollectedfrom
arelative,whohasbeenobservingthepatientduringmostpartofhisillness.

9. 9 11/28/2021
Cont.PRINCIPLESOFCLINICALMETHOD
•Properlyorganizedapproach(NOPROPERSEQUENCE)
Theexperienceddoctorbeginstheconsultationfromthemomentthepatientwalksinto
theroom,thegeneralappearance,dress,attitude,gait,vocabulary,personalityandonly
finishedwhenthepatienthasleft.
•Patient–DoctorRelationship
Vocaltones,bodylanguage,openness,presenceandconcealmentofattitude,maintain
aprofessionalrapport,upholdpatients’dignityandrespecttheirprivacyetcareresponsible
forasatisfactoryestablishmentofPatient–Doctorrelationship.
•Information
Informationregardingillnessshouldalwaysbeobtainedfromthepatienthimself,
wheneverthepatientisinafitstatetocommunicate.Incaseofpatient’sconsciousnessis
disturbedorhe/sheiscriticallyillormentallyinfirm,suchinformationmaybecollectedfrom
arelative,whohasbeenobservingthepatientduringmostpartofhisillness.

10. 10 11/28/2021
MEDICAL RECORDS
Personal health records(P.H.R.)
Achronologicalwrittenaccountofindividualpatient'sexaminationandtreatmentisknownasthat
individualpatient’smedicalrecord.
Themedicalrecordincludesavarietyoftypesof"notes"enteredovertimebyhealthcareprofessionals.
Thisincludes
Admissionnotes(Bio-data,History,physicalfindingsetc)
Diagnostictestresults(Pathology,x-rays,ECG,USGetc)
Diagnosis
Medicationsandtherapeuticprocedurenotes(Preoperative,Operative,postoperative,deliverynotes,
postpartumnotesetc
Progressnotesofobservationsandmedications
Dischargenotes
InformationinmedicalrecordsissensitiveasPersonalinformationcoveredbyexpectationsofprivacy,so
manyethicalandlegalissuesareimplicatedintheirmaintenance.

11. CLINICAL METHODS
Personal details

12. PERSONAL DETAILS
(BIODATA)
1. NAME
2. AGE
3. SEX
4. ADDRESS
5. RELIGION&CASTE
6. MARITALSTATUS
7. OCCUPATION

13. 11/28/202113
•NAME
Name&Surnamehastobecorrectlyrecordedforeasyidentification.Thishasalso
additionalimportanceformedicolegalcases(MLC)andinsurancepurposes.
•AGE
Somediseasesoccurringcommonlyinoneextremeoftheageandarerareintheother
extreme.Forexample-
Childhood-Rheumaticfever,Measles,Diphtheria
Middleage-ChronicMyelocyticLeukemia,Pepticulcer
Oldage–Malignancies,Ischemicheartdisease
•SEX
Somediseasesarefoundinaparticularsex.Forexample–Hemophiliaoccursexclusively
inmalesandPrimarypulmonaryhypertensionandsystemiclupuserythematous are
commonlyseeninfemales.

14. 11/28/202114
•ADDRESS
Addressisrequiredforrecordandfuturecorrespondence,besidescertaindiseasesare
commonincertainlocalities.Endemicgoiterbeingcommonlyfoundinmountainousareasand
filariasisinthecostalregions.
TheaddressmustwrittenaccuratelyindetailLike
→C/O(S/O,D/O,W/O)
→A.T.,P.O.,P.S.,DIST.,PHONEETC.
(P.S./Policestationmustbethereasdealwithmedicolegalcases/MLC)
→AlsoEntrythenameandaddressofthepersonwhobroughtthepatienttohospital.
•RELIGION&CASTE
Sicklecellanemiaisseeninaspecialcasteofpeoples.Carcinomaofpenisisextremely
rareinMuslimsbecauseofthepracticeofcircumcisionduringchildhood;whereasitishighin
allotherreligiousgroupswheresuchpracticeisnotadopted.

15. 11/28/202115
•MARITALSTATUS
Hemophiliaistransmittedbyfemalestomales.Diseaseshavinghomozygousrecessive
heritancearegreatlyinfluencedbygenotypeofthecouple.
•OCCUPATION
Occupationhasagreatbearinginthecausationofsomediseasesknownasoccupational
hazardsoroccupationaldiseases.
Forexample–Peopleexposedtoradiationaremorepronetocancerwhereas
Pneumoconiosisiscommon amongthemineworkers.Incaseofchildwriteparent’s
occupation.

16. 16 11/28/2021
SYSTEMIC
EXAMINATIONS
GENERAL
EXAMINATIONS
PERSONAL DETAILS
DIAGNOSIS
&
TREATMENT
THE HISTORY
PHYSICAL & MENTAL
EXAMINATIONS
PROVISIONAL
DIAGNOSIS
------------------
INVESTIGATIONS

17. 11/28/202117
DEFINITIONOFMEDICALHISTORY
Itistherecordofmedicaleventsthathavealreadytakenplaceinthepatient.
Historytakingisanart,whichadoctorlearnsovertheyearsbyrepeatedpracticeandexperience.
PRINCIPLESOFHISTORYTAKING
Putthepatientinease,chooseanappropriatesetting.
Startbyelicitingthepresentingcomplaint
Encouragethepatienttogiveanuninterruptedhistory.
Uselanguagethepatientunderstands.
Avoidsuggestingsymptomsoranswerstothepatient.
Writenoteswhilethepatientistalking.
Useselectivequestionstoclarifythepresentinghistory.
Usefurtherquestionsofdiagnosticrelevance.
Askcardinalquestionswhichreviewingthesystems.

18. COMPONENTS OF THE
HISTORY TAKING
1.ChiefComplaint(S)
2.PresentHistory/HistoryOfPresentIllness
3.PastHistory/HistoryOfPastIllness
4.FamilyHistory
5.PersonalHistory(Socio-economical-occupationalhistory)
6.TreatmentHistory/DrugHistory
7.Obstetric&gynecologicalhistory
8.Sexualhistory
9.Psychiatrichistoryetc

19. CHIEF COMPLAINT (S)

20. 20 11/28/2021
CHIEF COMPLAINT (S)
Themaincomplaintwhichmadethepatienttovisittothedoctor.Somepatients
havemorethanonecomplaints.
Principles
Thisshouldberecordedusingthepatient'sword,ratherthanmedicaltermslike
→Chestpainonwalkinguphillshouldnotbetranslatedintoanginaofeffortwhich
maybiasthecriticalevaluation.
Thisshouldbenotedinclearchronologicalorderwithduration(ifavailable)i.e.If
patientexplainwithduration,thenwriteithere.Otherwisedon’tdisturbinmiddle.
Leadingquestionsshouldnotbeaskedatthisstageofhistorytaking.
Abbreviations-CC/PresentingComplaint(PC)/ReasonforEncounter(RFE)/Presenting
Problem/Problemonadmission/ReasonforPresenting

21. HISTORY OF
PRESENT ILLNESS

22. 22 11/28/2021
PRESENT HISTORY / HISTORY OF PRESENT ILLNESS
Thispartofthehistorytakingreferstoadetailedanalysisofsymptoms.Oncethe
patienthashadtimetocommunicatetheirpresentingcomplaint,thenbegintoexplorethe
issuewithfurtheropenandclosedquestions.
Principles
Askthepatienttotellthestoryofhis/herillnessfromthebeginninglikeonset,progress
etc.
Leadingquestionsmayhavetobeaskedinordertoelicitadequateinformationbutnot
unnecessaryleadingquestionsbecauseapositivereplyisoflimiteddiagnosticvalue.
Repliesinnegativeshouldalsobetakenintoconsideration.
DifferentsourcesincludedifferentquestionstobeaskedwhileconductinganPresent
History.
Abbreviations -History Of Present Illness(HPI) (H/O present illness) / History Of Presenting
Complaint (HPC) / Present History / Case Of (C/O)

23. 23 11/28/2021
PresentHistorymaydividedintothreeparts
foreasyelaboration-
1.GENERALINTERROGATION
2.SYMPTOMS ANALYSIS
3.SYSTEMICINTERROGATION

24. 24 11/28/2021
GeneralInterrogations
1.Whenwashe/sheapparentlywell?(Whendidthesymptom
start?)......(DURATION)
2.Howwastheonsetoftheillness–Acute/Gradual/Insidious…….
3.Inwhatchronologicalorderthesymptomsappeared……..
4.Howhavethesymptomsprogressed/modifiedduringthecourseof
illness…
5.Whetheranytreatmenthasbeenreceived&ifsowhathavebeen
theresultofsuchtreatment.............

25. 25 11/28/2021
Example-1
Thepatientwasapparentlywellbefore3days.Suddenlychill&rigorstarted.
Aftersometimestemperatureriseshighly.Thenallsubsidedautomaticallywithprofuse
sweating.Todaysimilarsymptomsrisesagainwithheadacheandvomiting.Patient
takingsomemedicinesbutnotrelieved.
Example-2
Weekbeforetheadmission,thepatientfellwhilegardeningandcuthisfoot
withastone.Bythatevening,thefootbecameswollenandpatientwasunabletowalk.
NextdaypatientattendedMerjanhospitalandtheygavehimsomeoralantibiotics.
Hedoesn’tknowthename.Thereisnoeffectonhisconditionandtwodayspriorto
admission,thefootcontinuedtoswellandstartedtodischargepus.Thereishighfever
andrigorswithnauseaandvomiting.

26. 26 11/28/2021
OPQRST
O-Onset
P-Provokingandpalliatingfactors
Q-Quality("Whatdoesitfeellike?")
R-Radiating(notinglocationoforigin)
S-Severity(usuallyuseascalefrom0-10)
T-Timing(constant,intermittent,duration,timeofday)
SOCRATES
S-Site
O-Onset
C-Characteristics
R-Radiating
A-Alleviating
T-Timing
E-Exacerbatingfactors
S-Severity
SYMPTOMS ANALYSIS
Eachsymptomshouldanalyzedvividly.Example–Pain/Headache/Breathlessness/
Tirednessetc
OLDCARTS
•O-Onset
•L-Location/Radiation
•D-Duration
•C-Characteristics
•A-Aggravatingoralleviatingfactors
•R-Relivingfactors
•T-Timing
•S-Severity

27. 27 11/28/2021
(OLDCARTS-Onset,Location/radiation,Duration,Character,Aggravatingfactors,Reliving
factors,TimingandSeverity)
•Onset:
Whendidthesymptomstart?WastheonsetacuteorgradualorInsidious?
Example–Acuteonset–fever,Gradualonset–Sciatica,Insidious–T.B.
•Location/radiation
Whereistheexactlocationpointofsymptom?
Doesthepainradiateanywhere?
Example-Shouldertippaincanoccurinectopicpregnancy
Anginapainoftenspreadstoneck,throat,lowerjaw,teethorshouldersandarms.
•Duration:
Howlongdidthesymptomlast?(e.g.minutes,hours,days,weeks,months,years)

28. 28 11/28/2021
•Character
Whatisthecharacterofsymptom?
Intermittentorcontinuous:
Isthesymptomalwayspresentordoesitcomeandgo?
Ifintermittent,howfrequentisthesymptom?
Example-Isthepainsharporadullache?Isthepainintermittentorcontinuous?
Isthefeverregularorirregular?
•Aggravating/Precipitatingfactors:
Arethereanyobvioustriggersforthesymptom?
Example–NSAIDsaggravatesgastricpain.Workloadprecipitatestress.
•Relievingfactors:
Doesanythingappeartoimprovethesymptoms?
Example–GastritisnotrelievedbyAntacidsbutrelivedbySorbitratesiscardiacorigin.

29. 29 11/28/2021
•Timing
constant,intermittent,duration,timeofday
Example-Whatistheoveralltimecourseofthepain?(e.g.worsening,improving,
fluctuating)
•Severity:
Howseveredoesthepatientfeelthesymptomis?
Isitimpactingsignificantlyontheirdaytodaylife?
Example-OnaVASscaleof0-10,howsevereisthepain,if0isnopainand10is
theworstpainyou’veeverexperienced.

30. 30 11/28/2021
Severalacronymshavebeendevelopedtocategorizetheappropriatequestionstoinclude.
(http://en.wikipedia.org/wiki/History_of_the_present_illness)
CMS
(Centres for
Medicare and
Medicaid Services)
"OPQRST"
or "PQRST"
"CLEARAST" "LIQOR AAA“
"SCHOLAR"
("S" = Symptoms)
"COLDER AS"
Location
"R": Region and
Radiation
"L": Location "L": Location "L:" Location "L:" Location
Quality
"Q": Quality of the
pain
"C": Character "Q": Quality "C:" Characteristics"C": Character
"R": Radiation "R": Radiation see above "R": Radiation
Severity "S": Severity "S": Severity "I": Intensity see above "S": Severity
Duration "O": Onset "T": Time frame "O": Onset
"O:" Onset
"H:" History
"D:" Duration
Timing "T": Time see above see above see above "O": Onset
Context
Modifying factors
"P": Provocation or
Palliation
"E": Exacerbation
"A": Aggravating
factors
"A:" Aggravating
factors
"E:" Exacerbation
"A": Alleviation
"A": Alleviating
factors
"R:" Remitting
factors
"R:" Remitting
factors
Associated signs &
symptoms
"A": associated
symptoms
"A": Associated
symptoms
see above
"A": Associated
symptoms

31. 31 11/28/2021
SYSTEMICREVIEW {Reviewofsystems/Directquestions}
•Itisatechniqueusedbyhealth-careprovidersforelicitingahistoryfromapatient
whichhavebeenforgottenordismissedbythepatientasunimportantorfora
verityofemotionalreasonsincludingembarrassment,anxietyorguilt.
Principles
•Itisnotnecessarytoaskeverypatientallsystemicinterrogations.Howeverwhile
learningtotakeahistory(students),itisusefultogothroughafullchecklist.
•Thenegativevaluesalsohaveimportantroleindiagnosis.Inanegativeresponse,
write“ROS–Allothersystemswerereviewedandarenegative”.
•Ifapositiveresponseiselicitedthenmoredetailedquestions(OLDCARTS-Onset,
Location/radiation,Duration,Character,Aggrevatingfactors,Relivingfactors,
TimingandSeverity)mayberequired.
Abbreviations–ROS/Reviewofsystems/systemsenquiry/systemsinterrogation

32. CARDINAL SYMPTOMS OF SYSTEMIC INTERROGATION
System Examples
General
(CONSTITUTIONAL)
SYMPTOMS
•UnexplainedWeightLoss/ChangeOfWeight
•NightSweats
•Fatigue/Malaise/Lethargy/Weakness
•SleepingPattern
•Appetite/Anorexia
•Fever
•Itch/Rash
•RecentTrauma
•Lumps/Bumps/Masses
•UnexplainedFalls

33. CARDINAL SYMPTOMS OF SYSTEMIC INTERROGATION
System Examples
C
A
R
D
I
O
V
A
S
C
U
L
A
R
S
Y
S
T
E
M
Chest(Precordial)Pain/Tightness-Origin&Radiation,Character,
Duration,Relieving&AggravatingFactors
ShortnessofBreath(Dyspnoea)OnExertion/Rest
Exerciseintolerance
BreathlessnessWhenLyingFlat(Orthopnoea)
AttacksOfNocturnalBreathlessness(ParoxysmalNocturnalDyspnoea/PND)
AnkleSwelling/Edema
Palpitations
Faintness
lossofconsciousness
PainInLegsOnExertion(Claudication)
HistoryOfCough/Expectoration/Haemoptysis (pinkish/frankblood)
DigestiveDisturbances
Cyanosis

34. CARDINAL SYMPTOMS OF SYSTEMIC INTERROGATION
System Examples
R
E
S
P
I
R
A
T
O
R
Y
S
Y
S
T
E
M
•Cough(Dry/Productive)-RelationWithPosture&Time
•SputumQuantity–Scanty/Profuse,Odour,
Character–Mucoid/Mucopurulent/Purulent
RelationWithPosture&Time
•PresenceOfWheezing/Strider
•ShortnessOfBreath:ExerciseTolerance
Precordial(Chest)Pain/Tightness-Origin&Radiation,Character,
Duration,Relieving&AggravatingFactors
•Tachypnoea
•Hoarseness
•Haemoptysis

35. CARDINAL SYMPTOMS OF SYSTEMIC INTERROGATION
System Examples
ALIMENTARY
SYSTEM
(Gastrointestinal)
•AbdominalPain-Character&TimeOfPain- Site&Radiation-
Periodicity-RelationWithFood/Alkali/Vomiting-.......
•Diet/Appetite(anorexia/weightchange).......
•HeartBurn/Regurgitation-AcidEructation/WaterBrash/Indigestion/
Bloating,Cramping/Anorexia/FoodAvoidance
•ChangeInBowelHabit(Diarrhea/Constipation/MucusMixed/DryHeavesOfThe
Bowels(Tenesmus)
•Nausea/Vomiting(Frequency&CharacteristicsOfVomitedMatter)/Vomiting
Blood(Haematemasis)
•ColourOfMotion(Pale/DarkBlackTarryStools(Malaena)/FreshBlood(Bright
RedBloodPerRectum-BRBPR,Hematochezia)
•Flatulence-FoulSmelling/InabilityToPassGas(Obstipation)
•Jaundice(Colour&Itching)

36. CARDINAL SYMPTOMS OF SYSTEMIC INTERROGATION
System Examples
U
R
I
N
A
R
Y
S
Y
S
T
E
M
Micturition–Irritativevs..Obstructivesymptoms
Incontinence,
Pain/BurningSensationOnPassingUrine(dysuria)
Haematuria
Nocturia
FrequencyOfPassingUrine(polyuria)
DifficultyInStartingToPassUrine(hesitancy)
terminaldribbling
decreasedforceofstream
AbnormalColourOfUrine(BloodEtc)

37. CARDINAL SYMPTOMS OF SYSTEMIC INTERROGATION
System Examples
G
E
N
I
T
A
L
S
Y
S
T
E
M
Male
•MentalAttitudeToSex
•MorningErections
•FrequencyOfIntercourse
•AbilityToMaintainErections
•Ejaculations
•UrethralDischarge
Female–(IfPremenopausal)
•AgeOfOnsetOfPeriods(Menarche)
•RegularitiesOfPeriods(E.g.28Day)
•LengthOfPeriods
•LosingMoreOrLessBloodThanUsual
•PrematureTension/PainAtPeriods
•UseOfContraception
•PresenceOfVaginalDischarge
Female–(IfPostMenopausal)
•Bleeding
•StressAnd/OrUrgeIncontinence
•Libido
•PainDuringIntercourse(Dyspareunia)
Breast
•Pain,soreness,lumps,ordischarge.

38. CARDINAL SYMPTOMS OF SYSTEMIC INTERROGATION
System Examples
N
E
R
V
O
U
S
S
Y
S
T
E
M
•Special Senses -Any Changes In Sight (Visual), Smell, Hearing And Taste
•Seizures, Faints, Fits, Black outs, loss of consciousness(LOC)
•Funny Turns
•Headache
•Pins And Needles (Paraesthesiae) Or Numbness / Abnormal sensation
•Limb Weakness / Paralysis
•Poor Balance
•Speech Problems
•Sphincter Disturbance
•Higher Mental Function And Psychiatric Symptoms, Change of behaviour
•Sleep Patterns
•Tremor

39. CARDINAL SYMPTOMS OF SYSTEMIC INTERROGATION
System Examples
MUSCULO
SKELETAL
SYSTEM
(LOCOMOTOR
SYSTEM)
•Pain(muscle,bone,joint)
•Misalignment(Deformities)
•Stiffness(morningvs.daylong;improves/worsenswith
activity)
•Jointswelling
•Decreasedrangeofmotion(ROM)
•Crepitus
•Functionaldeficit(Weakness/movement )
•Arthritis

40. CARDINAL SYMPTOMS OF SYSTEMIC INTERROGATION
System Examples
INTEGUMENTARY
SYSTEM
(SKIN)
•Pruritus
•Rashes
•Stria
•Lesions
•Wounds
•Incisions
•AcanthosisNigricans
•Nodules
•Tumors
•Eczema
•ExcessiveDrynessAnd/OrDiscoloration

41. CARDINAL SYMPTOMS OF SYSTEMIC INTERROGATION
System Examples
Eyes
•Visualchanges
•Headache
•Eyepain
•Doublevision
•Scotomas(blindspots)
•Floatersor"feelinglikeacurtaingotpulleddown"
(retinalhaemorrhagevs.Amaurosisfugax)

42. CARDINAL SYMPTOMS OF SYSTEMIC INTERROGATION
System Examples
MOUTH AND EAR,
NOSE, THROAT
(ENT)
•RunnyNose
•Frequent Nose Bleeds
(Epistaxis)
•SinusPain
•StuffyEars
•EarPain
•RingingInEars(Tinnitus)
•GingivalBleeding
•Toothache
•SoreThroat
•ConditionOfMouth(InfectedTongue
/BleedingGums)
•PainWithSwallowing(Odynophagia)
•Difficulty With Swallowing
(Dysphagia)(SolidsVs.Liquids)
•IncreasedThirst…
•IncreasedSalivation…
•DisordersOfTaste.....

43. CARDINAL SYMPTOMS OF SYSTEMIC INTERROGATION
System Examples
Psychiatric
•Depression
•SleepPatterns
•Anxiety
•DifficultConcentrating
•BodyImage
•WorkAndSchoolPerformance
•Paranoia
•Ahedonia
•LackOfEnergy
•EpisodesOfMania
•EpisodicChangeInPersonality
•ExpansivePersonality
•SexualOrFinancial'Binges’

44. CARDINAL SYMPTOMS OF SYSTEMIC INTERROGATION
System Examples
Endocrine
SYSTEM
•Hyperthyroid:prefercoldweather,moodswings,sweaty,diarrhoea,oligomenorrhoea,weight
lossdespiteincreasedappetite,tremor,palpitations,visualdisturbances
•Hypothyroid-preferhotweather,slow,tired,depressed,thinhair,croakyvoice,heavy
periods,constipation,dryskin
•Diabetes:polydipsia,polyuria,polyphagia(constanthungerwithoutweightgainismoretypical
foratypeIdiabeticthantypeII)
•Hypoglycemia-dizziness,sweating,headache,hunger,tonguedysarticulation
•Adrenal:difficulttotreathypertension,chroniclowbloodpressure,orthostaticsymptoms,
darkeningofskininnon-sunexposedplaces
•Reproductive(female):menarche,cycledurationandfrequency,vaginalbleedingirregularities,
useofbirthcontrolpills
•Reproductive(male):difficultywitherectionorsexualarousal,depression,lackof
stamina/energy

45. CARDINAL SYMPTOMS OF SYSTEMIC INTERROGATION
System Examples
Hematologic
/
lymphatic
SYSTEM
•Anemia
•Purpura
•Petechia
•ResultsFromRoutineHemolyticDiseasesScreening
•ProlongedOrExcessiveBleedingAfterDentalExtraction/Injury
•UseOfAnticoagulantAndAntiplateletDrugs(IncludingAspirin)
•FamilyHistoryOfHemophilia
•HistoryOfABloodTransfusion
•RefusedForBloodDonation
•"DifficultyBreathing"Or"Choking"(Anaphylaxis)AsAResultOfExposureToAnything(And
StateWhat;E.G."BeeSting“)
•SwellingOrPainAtGroin(s),Axilla(e)OrNeck(SwollenLymphNodes/Glands)
•AllergicResponse(Rash/Itch)ToMaterials,Foods,Animals(E.G.Cats),ReactionToBeeSting
•UnusualSneezing(InResponseToWhat),RunnyNoseOrItchy/TearyEyes;
•Food,MedicationOrEnvironmentalAllergyTest(s)Results.

46. CARDINAL SYMPTOMS OF SYSTEMIC INTERROGATION
System Examples
Allergic / Immunologic
•"DifficultyBreathing"Or"Choking"(Anaphylaxis)AsAResultOfExposure
ToAnything(AndStateWhat;E.G."BeeSting“)
•SwellingOrPainAtGroin(s),Axilla(e)OrNeck(SwollenLymph
Nodes/Glands)
•AllergicResponse(Rash/Itch)ToMaterials,Foods,Animals(E.G.Cats),
ReactionToBeeSting
•UnusualSneezing(InResponseToWhat),RunnyNoseOrItchy/Teary
Eyes;
•Food,MedicationOrEnvironmentalAllergyTest(s)Results.

47. PAST HISTORY

48. 48 11/28/2021
PAST HISTORY (History of past illness)
Apastmedicalhistoryisthetotalsumofapatient'shealthstatuspriorto
thepresentingproblemi.e."thepatient'spastexperienceswithillnesses,operations,
injuriesandtreatments“.
Principles
•ThetermHospitalizationsincludesallmedical,surgicalandpsychiatric
hospitalizations.
•Notethedate,reason,durationforthehospitalization.
Abbreviations–Historyofpastillness/PastMedicalHistory/PMH

49. 49 11/28/2021
WhileconductingaPMH,differentquestionstobeasked.Theyinclude
SimilarSymptomsInThePast(ConditionsThatMayRecur)
Ex–PepticUlcer,Asthma,Allergy
ProlongedIllnessInThePast(ChronicConditions)-
Ex–Diabetes,HeartDisease,Epilepsy,hypertension,cancer
SeriousIllnessInThePast(ConditionsThatMayGiveRiseToLongTermComplications)-
Ex–JaundiceleadstoCirrhosisOfLiver,Diabetes,HypertensionleadstoIschemicHeart
Disease.
SurgicalHistory&anyComplications
Notethetypeofprocedure,date,hospital,surgeon,anycomplicationsandfollowup
arrangements.Notethetypeanddateofinjuryoraccidents.
(Infemales)Obstetric&GynecologicalHistory&anyComplications-
Totalnumberofpregnancies,whethertheyarefullterm,preterm,miscarriages,abortions,
living,aswellasanycomplications.Thisincludemenopauseanddate.Includesexualhistory
andanyhistoryofsexuallytransmitteddiseases.

50. Birthhistory:
Detailsoflabouranddeliveryofpatient,admissiontoNICU,maternalfever,durationof
ruptureofmembranes,APGARscores(particularlyimportinfirstthreemonthsoflife)
Growthanddevelopment:
Plotsofheight,weight,andheadcircumferencearestandardcontentforpaediatricrecords,
anychangeintrajectory(e.g.growthplotswhichcrosspercentilelinesratherthanrunning
parallel),developmentalmilestones,anyIQorotherdevelopmentaltesting
Allergies-
Noteanyenvironmental,food,latexordrugallergies,aswellasthespecifictypeofreaction,
e.g.anaphylaxis,rash,itching.
Immunizations–
Takeacarefulrecordofallimmunizations,includingtetanus,diphtheria,pertussis,polio,
HepatitisB,measles,mumps,rubella,etc
OtherSourcesOfInformation
PreviousMedicalRecords/RadiographsEtc

51. FAMILY
HISTORY

52. FAMILY HISTORY
Afamilyhistoryconsistsofinformationaboutdisordersfromwhichthedirectblood
relativesofthepatienthavesuffered.
Principles
Howmanychildren&siblingsareinthefamily?
Allcloserelatives(parents/sibs/children)alive-
Ifnot,whatwasthecauseofdeath&ageofdeath?
Ifalive,dotheyhaveanysignificantillnessoraretheyonknownmedications
IsthereAfamilyhistoryofanyrelevantspecificconditions(ex–diabetes,hypertension,
thyroiddiseaseetc)
Incomplexsituations,afamilytreeorgenogrammaybeusedtoorganizetheresulting
information.
Abbreviations–FH

53. FAMILY TREE
OR
GENOGRAM
Term Definition
First cousin • The children of two siblings.
Second cousin • The children of two first cousins.
Third cousin • The children of two second cousins.
First cousin once removed • Two people for whom a first cousin relationship is one generation removed.
First cousin twice removed • Two people for whom a first cousin relationship is two generations removed.
Second cousin once removed • Two people for whom a second cousin relationship is one generation removed.

54. Exampleofsomegeneticallytransmitteddiseases
X-Linkedrecessivediseases
•Ex.–Duchenemusculardystrophy,Hemophilia,G6PDdeficiency,etc)
Womenarecarriersanddonotsufferfromthediseasewhereasmalessufferfromthe
disease.Henceinsuchillnesses,thefamilyhistorywouldsuggestsimilarillnessinthepatient’sbrothers,
sister’ssons,mother’sbrother,mother’sbrother’ssons.
Autosomaldominantdisorders
•Ex.–FamilialHyperlipidemias,PolycysticKidneys,Neurofibromatosisetc)
Therewillbeafamilyhistoryofsimilarillnessineitheroftheparentsand/orGrandparents.
Autosomalrecessivedisorders
•Ex.–Sicklecellanemia,Thalassemiaetc)
Thereisusuallynohistoryofsimilarillnessintheparentssincetheymaybeheterozygous
andhenceonlycarriers.Howeverhistoryofconsanguineousmarriageintheparents(marriagebetween
cousinsorbrothers&sisteroruncleorniece)maybepresentandmayberesponsibleforthe
homozygousstateinthepatientandthusthemanifestationofthedisease.

55. Difficulties
Familyhistoriesmaybeimprecisebecauseofvariouspossiblereasons:
•Adoption,fostering(bringup),illegitimacy(notlawfullymarried)andadultery(voluntarysexualcontactbetween
marriedpersonwithother)
•Lackofcontactbetweencloserelatives
•Uncertaintyabouttherelative'sexactdiagnosis
•Somemedicalconditionsarecarriedonlybythefemaleline,andtracingfemale
ancestorscanbedifficultinsocietiesthatchangethewoman'sfamilynamewhenshe
marries.
•Othermedicalconditionsarecarriedonlybythemaleline.Tracingmaleancestors
maybeimpossibleiftheconceptionisduetorapeorsexualactivityoutsideofa
marriage.
fostering(bringup),
illegitimacy(notlawfullymarried)
adultery(voluntarysexualcontactbetweenmarriedpersonwithother)

56. Personal History
(Socio-Economic Occupational History)

57. PERSONAL HISTORY
(SOCIO-ECONOMIC OCCUPATIONAL HISTORY)
PersonalhistoryisaportionoftheAdmissionnoteaddressingfamilial,
occupationalandrecreational(activityofleisure)aspectsofthepatient'spersonallife
thathavethepotentialtobeclinicallysignificant.
Anindividualsadaptiontohisoccupationalandsocialenvironmentmay
profoundrepercussiononhishealth.Itmayhelpnotonlyinrelationtodiagnosisbut
alsointheplanningofrehabilitation.
Abbreviations–SocHx/Socio-EconomicOccupationalHistory

58. 58 11/28/2021
Whentakinghistoryitisusefultoenquiryaboutthefollowings.
SOCIALLIFE
•Homesurroundings
•Amount&quantityofsleep
•Personalinterest&Habits
•Domestic&Maritalrelationship
•Travel
•Prisonetc.
ECONOMICAL CONDITION
OCCUPATIONAL HISTORY

59. SOCIALLIFE
HOMESURROUNDINGS :-Itmaybehelpfultoknowaboutthedetail’sofpatient’shome&
it’ssurroundingsincludinglivingarrangements.Forexample-
•Sanitaryconditions(?-infection)
•Thepossibleexistenceofovercrowding(?-T.B.)
•Loneliness(?-Depression)
•Numberofstepsleadinguptotheroomorbedroom(?-Angina,Chronicbronchitis,R.A.)etc.
AMOUNT &QUANTITY OFSLEEP:-Doesthepatienttakehypnoticstosleep?Sleep
disturbancesarecommoninanxietystatesandmanypsychoses.Ausefulmnemonicforsleep
patternsisBEARS,
•Bedtimeproblems(e.g.snoring,sleepapnea,ornightmares)
•Excessivedaytimesleepiness
•Awakeningsatnight
•Regularityanddurationofsleep
•Snoring

60. PERSONAL INTEREST&HABITS:-
•Appetite&FoodHabits
•Bowel&MicturitionHabits
•Addictions
•Diet&OtherBeverages
•SexualActivity
Appetite&FoodHabits-Lossofappetiteandweightmaysuggestanactivediseaseprocess.
Bowel&MicturitionHabits-Thisalsoimportantindiseaseprocesslikediabetes,IBSetc.
Addictions–Thetype,amount,durationaswellasanypasttreatmentordrug
rehabilitationonaddictionsaretobenoted.
Examplesofaddictions
Alcohol
Smoking
Tobaccochewing(packyears)
IllicitDrugs/Recreationaldruguse(Charas,Ganja,Marijuana,Drugabuseetc)

61. 61 11/28/2021
Diet&OtherBeverages–
→Typeofdietmayhaveimportantimplicationinrelationtonutritionalproblems,psychological
instabilityandlungdiseases.Askabouteverythingthepatienthaseatenthedaybeforeand
forthepastweek.Notethetypeoffoodconsumedanddoanutritionalstatusassessment.
→Patient’sleisurepursuitsallowsabetterappreciationofthepatient’slifestylelikejoiningparty
etc.Thismayexposetoenvironmentalpathogensthroughrecreationalactivitiesorpets.
Forexample–
•Excessuseofwineinparty-Theregularconsumptionofmorethan21unitsofalcoholperweekin
malesor14unitsinfemales,confersasignificantriskofdevelopinganalcoholrelateddisorder.These
includechronicliverdisease,peripheralneuropathy,cerebralatrophy,pancreatitis,andalcoholic
cardiomyopathy.Thereisalsoaliabilitytodevelophypertension.
•Amenorrhoeaiscommoninyoungwomenwhotakealotofphysicalactivity.
SexualActivity:Thisisanuncomfortablelineofquestioningformanypractitioners.However,itcan
provideimportantinformationandshouldbepursuedasthereisincreasedriskofvariousinfectionsamong
prostitutes,johnsandmalesengaginginanal-receptiveintercourse.

62. DOMESTIC&MARITALRELATIONSHIP :-Itisofgreatimportantinpsychoneurosis.His
feelingsaboutothermembersofhisfamilyandrelativesandtheopinionofother
membersabouthimaretobecarefullyrecorded.
RESIDENCE /TRAVELOTHERPLACES:-ByRecentforeigntravelInfectionmaybe
transmittedtoanarea,whereitisnotnormallyencountered.Ex–COVID19,EBOLA,
SARSetc.
PRISON-Especiallyiftuberculosisneedstoberuledout.
ECONOMICAL CONDITION
Upperclass
Uppermiddleclass
Lowermiddleclass
Poorclass
Aperson’ssocialclasshasasignificantimpactontheirphysicalhealth,theirabilitytoreceive
adequatemedicalcareandnutrition,andlevelsofhealthinsuranceetc.Socialdeterminantscan
beusedtopredictone’sriskofcontractingadiseaseorsustaininganinjuryetc.

63. OCCUPATIONAL HISTORY
TherelevantaspectsofOccupationalhistoryincludecompensationforan
occupationalrelatedillness/accidentorthereceiptofapension/invaliditybenefit.
Example:-
•Miningindustries-Silicadust-Silicosisofthelungs
-Asbestosfiber-Asbestosisoflungs
•Exposuretodustofmouldyhay-Farmer’slungfrom
Itisnecessarytoknowtheexactnatureofhispresentwork&previouswork,
hoursofwork,theplaceofworkandwhetheritexposeshimtoinjuriousinfluences.

64. Questionsrelatedtooccupationalhistory
•Askabouthisattitudetohiswok,hisemployers,hisworkmatesandthepossibilityoffinancial
worries.
•Isthejobdustyandifsowhattoolsmakethedust?
•Aretherefumesorvaporsandifsowhatarethechemicalsubstancesinvolved?(mostofthe
toxicsubstancesencounteredindangeroustradesenterthebodybyinhalation,althoughsome
solventspenetratetheskin).
•Ishoodinstalledoverthebenchandisitconnectedtoasuctionsystem?
•Isprotectiveclothingprovided?
•Isaspecialsuitorgogglesrequiredandwhy?
•Hasanysimilarillnessaffectedafellowemployee?(certainoccupationalhazardsareassociated
withofficeworks,forexample–repetitivestraininjuryandmigraineinducedbystressor
inappropriatelighting.)

65. Drug History
(Treatment History)

66. DRUG HISTORY (TREATMENT HISTORY)
TreatmentHistoryisaportionoftheadmissionnoteessentialtoobtainfulldetailofall
thedrugsandmedicines(includingAYUSH,Alternativetherapiese.g.acupuncture,massage,
herbalmedicine,vitamins,chiropracticeandlaxativesetc)takenbythepatient.
Principles
•Checkallpreviousprescriptionsatthisstage.(Notbeforethisstage,becausewrongdiagnosis
maybiased)
•Askaboutknowndrugallergiesorsuspecteddrugreactions.Recordthisinformationinsucha
wayonthefrontofthenotesthatitisobvioustoanydoctorseeingthepatient.
•Notewhetherconcerningmedicationprescribedorselfadministered,takingthemedications
accordingtotheprescribedinstructions.,whethertakenregularlyoratwhimandiftherehas
beenrecentsuddenincreaseorreductioninthedosage.
•Directquestionsshouldbeaskedaboutname,dosage,frequencyofanymedication,including
anyover-the-countermedications.

67. 67 11/28/2021
Abbrev. Meaning
Latin(orNew
Latin) origin
a.c. beforemeals ante cibum
a.d., ad, AD right ear auris dextra
a.m., am, AM morning ante meridiem
a.s., as, AS left ear auris sinistra
a.u., au, AU
both ears togetheroreach
ear
aures unitasorauris
uterque
b.d.s, bds, BDS 2 times a day bis die sumendum
b.i.d., bid, bd
twice a day / twice daily / 2
times daily
bis in die
gtt., gtts drop(s) gutta(e)
h., h hour hora
h.s., hs at bedtimeorhalf strength horasomni
ii two tablets duos doses
iii three tablets trēs doses
n.p.o., npo, NPO
nothing by mouth /not
byoral administration
nil per os
nocte every night OmneNocte
o.d., od, OD
once aday
righteye
omnein die
oculus dexter
o.s., os, OS lefteye oculus sinister
o.u., ou, OU botheyes oculus uterque
p.c. afterfood post cibum
p.m., pm, PM afternoonorevening post meridiem
p.o., po, PO
orally / bymouth/oral
administration
per os/nonstandard
formper orem
p.r., pr, PR rectally per rectum
p.r.n., prn, PRN
as needed, (also Pertactin-
a key antigen of ac.Pertussis
vaccine)
pro re nata
Abbrev. Meaning
Latin(orNew
Latin) origin
q. every quaque
q.1.d., q1d everyday quaquedie
q.1.h., q1h everyhour quaque hora
q.2.h., q2h every 2 hours quaque secunda hora
q.4.h., q4h every 4 hours quaquequartahora
q.6.h., q6h every 6 hours quaque sexta hora
q.8.h., q8h every 8 hours quaque octava hora
q.a.m., qAM, qam everymorning quaque ante meridiem
q.d., qd every day / daily quaque die
q.d.s, qds, QDS 4 times a day quater die sumendum
q.h., qh everyhour, hourly quaquehora
q.h.s., qhs every night at bedtime quaque hora somni
q.i.d, qid 4 times a day quaterin die
q.o.d., qod
every otherday/
alternate days
quaquealteradie
q.p.m., qPM, qpm
everyafternoonoreven
ing
quaquepost meridiem
q.s., qs
a sufficient quantity
(enough)
quantum sufficiat
q.wk. also qw weekly (once a week)
Rx, Rx,℞ prescription recipe
Sig., S. directions signa
Stat.
immediately, with no
delay, now
statim
t.d.s, tds, TDS 3 times a day terdie sumendum
u.d., ud asdirected utdictum

68. Obstetric & Gynecological History

69. OBSTETRIC & GYNECOLOGICAL HISTORY
Menstrual history Obstetric History
•Ageatmenarche
•Lastmenstrualperiod
•Duration/Frequency
•Menstrualbloodflow-light/heavy
•Menstrualpain(prematuretension/presence/absenceofpainatperiods)
•Useoforalcontraception
•Totalnumberofpregnancies(Gravidity/G)
•Fullterm(Parity/P)
•Preterm
•Miscarriages
•Abortions(A)
•Living(L)
•Detailsofeachpregnancyincludingmode
ofdeliveryandcomplications
Gynecological History
•Ageatmenopause(ifappropriate)
•Abdominal/pelvicpain
•Post-coitalvaginalbleeding
•Intermenstrualbleeding
•Post-menopausalbleeding
•Abnormalvaginaldischarge
•Dyspareunia
•Vulvalskinchangesanditching
•Sexualhistoryifrelevanttopresentingcomplaint
•Anyhistoryofsexuallytransmitteddiseases

70. Psychiatric History

71. PSYCHIATRIC HISTORY
•Thereisnofundamentaldifferencebetweenapsychiatrichistoryandanyothermedicalhistory.
•Howeverpsychiatrichistoriesgenerallyneedtobemoredetailedandthereforetakelonger
becausemoreinformationisneededaboutthepatient’spersonallife,developmentalhistory,
familyandsocialbackground.
•Thisisthencombinedwiththementalstatusexaminationtoproducea"psychiatric
formulation"ofthepersonbeingexamined.
•Thisispartlybecauselaboratorytestsandinvestigationsalsocontributesolittletodiagnosis.
•COASTMAP isamnemonicacronymtorememberkeyquestionsforaperson'spsychiatric
history.
C—Consciousness O—Orientation A—Activity S—Speech
T—Thought M—Memory A—Affectandmood P—Perception

72. 72 11/28/2021
MoodDisorders
•Depression-"SIGECAPS“
(Lowmood>2weeks)
Sleep
Interest(anhedonia)
Guilt/worthlessness
Energy↓
Concentration↓
Appetite/weightchange
Psychomotorslowing/agitation
Suicide:thought/plan/access
•Mania-"GIDDINESS“Grandiose
Increasedactivity(goaldirected/highrisk)
Decreasedjudgment
Distractible
Irritability
Needlesssleep
Elevatedmood
Speedytalking
Speedythoughts
Grandiose –conceived on a very grand or ambitious scale

73. 73 11/28/2021
AnxietyDisorders
•GeneralizedAnxietyDisorder(Excessiveanxietyandworrythatisdifficulttocontrol
Restlessness(feeling“onedge”or“woundup”)
Fatigue
Concentration↓
Irritability
Muscletension
Sleepproblems
•SocialPhobia(SocialAnxietyDisorder-Fear/avoidanceofsocialperformancesituations)
Anticipatesembarrassingoneselfinsocialsituations
Hypersensitivetocriticism
Mayprecipitatepanicattacks
•SpecificPhobia(Mayincludeanimals,heights,blood/infection,flying,etc.)

74. 74 11/28/2021
Panicdisorderwith/withoutagoraphobia
•Panicattacksmayinclude:
Shortnessofbreath
Palpitations,poundingheart,oracceleratedheartrate
Sweating,trembling,shaking
Feelingofchoking
Chestpain/discomfort
Feelingnauseated,dizzy,faint,lightheaded
Abdominaldiscomfort
Derealization/depersonalization
Fearofdying,losingcontrol,goingcrazy
Chillsorhotflashes
Paresthesias

75. 75 11/28/2021
Obsessive-compulsivedisorder(OCD)
•Obsession:arecurrentandpersistentidea,thought,impulse,orimagethatisexperiencedasintrusive
andinappropriatethatcausesmarkedanxiety/distress.Themesincludeaggression,contamination,
symmetry,sexuality,hoarding,religion,somatic/appearance/body
•Compulsion:arepetitive,intentionalbehaviourperformedinresponsetotheobsession.Repetitivehand
washing,checking,counting,praying
Post-traumaticstressdisorder(PTSD)
•Recurrent,intrusiverecollectionsofthetrauma
•Nightmaresoftheevent
•Avoidanceofstimuliassociatedwiththetrauma
•Illusions,hallucinations,dissociative“flash-backs”
•Sleepdifficulties
•Irritability
•Decreasedconcentration
•Hypervigilance
•Startleseasily
•Anhedonia,detachmentfromothers,restrictedrangeofaffect

76. Psychosis
Positivesymptoms
Hallucinations
Delusions
Negativesymptoms
Flattenedaffect
Anhedonia
Avolition
Alogia
"Thoughtblocking"
Disorganization
Thinking
Speech
Behaviour
Cognitivesymptoms
Memoryimpairment
Attentiondifficulties
Deficitsinprocessinginformation
Catatonicsymptoms
Posturing
Excessmotoractivity
Rigidity
Stupor
Eating Disorders
•Binging / purging /
restrictions/amenorrhea
•Perceptionofbodyimageor
weight

77. 77 11/28/2021
Attention-Deficit/HyperactivityDisorder
•Inattention
Oftenmakescarelessmistakes
Difficultysustainingattention
Listeningdifficulties
Difficultyorganizingtasksandactivities
Avoidsattention-heavytasks
Loosesimportantitems(e.g.,keys,wallet,mobilephone)
•HyperactivityandImpulsivity
Fidgetswithhandsandfeet
Troubleremainingseatedwhenexpected
Runsandclimbsininappropriatesituations
Unabletoparticipateinleisurelyactivities
Unabletobestillforextendedperiodsoftime
Talksexcessively
Troublewaitingfortalkinconversation
Troublewaitingforturn
Interruptsorintrudesonothers

78. Sexual history

79. 79 11/28/2021
SEXUAL HISTORY
Alltheusualthings:CC,historyofPC,medical/surgicalhistory,medications/allergies,
gynaehistoryforwomen,socialhistoryPLUSthesexualhistory.
Principles
•Practicepokerface(blankexpression)
•Explaintheneedtotakeasexualhistory:
•Language–makesureyoubothunderstand
•Confidentiality–room/ward,relatives,interpreters

80. 80 11/28/2021
Questionsrelatedtooccupationalhistory
Sexualorientation(person'sfeelingsandsenseofidentity)
Sexualcoercionandabuse(trickedandforced)
Sexualactivity
Numberofpartners
Frequencyofintercourse
Typeofsexpractices
STIhistoryandriskassessment–(affecttheGenitalarea-Sexuallytransmittedinfectionse.g.syphilis,
scabies.,Medicalconditionspsoriasis,lichenplanus,diabetes,,Sideeffectsfrommedicinesrashordryness
etc)
Pregnancyhistoryandriskassessment
Contraceptivebehaviors(condomused/diditbreaketc)
Medicalprocedures/bloodtransfusions
Tattoos/piercingsinnon-professionalplace
Substanceuse(alcoholordrugs)
Socialhistoryofpartners(Generalhealth/knowninfection-Bacterialvaginosis,warts/useofDrugs
/alcohol/Smoking)

82. CONCLUSION ONHISTORYTAKING
•Thehistoryisthefirststeptowardsmakingadiagnosis.
•Atthisstagebyanalyzingtheavailableinformation,itshouldbepossibletoreachaprovisional
diagnosis.Thiswillinfluencetheemphasisplacedondifferentcomponentsofthephysical
examination.
•Theflexiblemethodofhistorytakingisimportantfortworeason.
1.Inmostinstancesitprovidesaclearindicationofthenatureoftheproblem.
2.Italsoformsthefoundationofasatisfactory“PATIENT-DOCTORRELATIONSHIP”
•Theskillofhistorytakingisnotacquiredovernightanditisnotappropriateforastudentto
askhighlypersonalorpotentialsensitivequestions.Howeveritshouldbeundertakenbya
doctorwhohasclinicalresponsibilityforthepatient.
•Students&Recentgraduatesshouldthereforetrytoavailthemselvesofanyopportunityto
“sit-in”duringsuchaconsultation.
History
(SAMPLE)
CC·HPI(OPQRST&ROS) · PMH· FH· SocHx· Allergies / Medications ·
Obs& Gynaehistory,Sexual history, Psychiatric history,

83. 11/28/202183
Medical profession is now a days Medico-legal profession, so SAVE YOURSELF
Respect all……………………..Suspect all