History taking-

1. THE ART OF HISTORY TAKING
DR SREEJOY PATNAIK
SHANTI MEMORIAL HOSPITAL
CUTTACK
5
TH
JANUARY 2013

3. 2013

11. TO ALL OF MY COLLEAGUES
•Nobody can teach you, unless you try to learn
•A teacher cannot teach u all the time, he can expose your
ignorance only.
•Don’t expect too much from a teacher because his knowledge
is limited.
•Rather, try to learn from the books under the guidance of
your teacher.
•Never compromise quality in learning. As the future( treating
& teaching ) will be in your hand.
•We may not be excellent , but have the scope to excel.

12. INTRODUCTION
•History taking skills is very much essential
in medical curriculum.
•Objectively being tested in formal exams
•Forms the basis of reaching a correct
diagnosis
•Often ignored/ proper emphasis is not
applied by many of us.

13. IMPORTANCE
•In HT we evaluate the feelings of a person.
•Sometimes we evaluate the Gestures when a
pt. is unable to express his feelings.
•Is there any equipment developed so far to
measure or assess the feelings & gestures of
man (patient)?
•Therefore HT & PE forms the foremost
aspect of Medical Science.
•It is considered as an Art.

14. •HT –a process to assess feelings.
•Feelings- symptoms of diff. diseases.
•- cannot be quantitated nor expressed in sc. terms
•Scientific understanding of disease- body changes
in terms of changes in anatomy & physiology.
•HT- assess bodily changes & its affect on mind.
•Non – verbal communications
•Body language- no physical ailment, but
symptomatic.

15. Importance of History Taking
•Obtaining an accurate history is the critical first
step in determining the etiology of a patient's
problem.
•A large percentage of the time ) 70%), you will
actually be able make a diagnosis based on the
history alone.

16. Introduce yourself.
• Note – never forget the patient names
• Be friendly and relaxed with the Patient.
•Respect Patient Confidentiality & Privacy.
General Approach General Approach
Try to see things from patient point of view. Understand
the patients mental status, anxiety, irritation or
depression.
Always exhibit neutral position.
Always Listen to the Patient.
Questioning: simple/clear/avoid medical terms/open,
leading, interrupting, direct questions and summarizing.

17. 1.To take a good history, one has to go down to the level of thinking the
pt
2. To identify the exact nature of work of the pt. & how the illness
affects his day to day work.
3.Understanding the language of the pt. is mandatory for correct
assessment of history.
4. Encourage him to speak freely without any reservation.
5. Create an environment for free talk
6. One should be attentive while listening the pt.,do not get diverted.
7.Do not show displeasure or dissatisfaction.
8. Privacy is important, no outsiders should be allowed.
9.Duty of the doctor is to collect a reliable history.
10. Always try to greet the pt. by name whenever possible.
11.Try to discuss topics unrelated to his ailment.
KEY POINTS

18. 12. If a pt. is giving unnecessary details of a minor point, do not get
irritatated, listen patiently & simultaneously ask details of points you
feel to be important.
13.Dissuade pts. Or attendants from speaking medical terms without
knowing the significance & meaning.
14.Dicourage pts. To tell about their t/t & show several consultation &
inv. papers.
15. Tell them to show them after the end of the conultation, because
these papers may misguide the DIAGNOSIS.
16. Critical ill pts.- save the life of the pt. first with min. history, stabilise
him, then collect data from relatives.
Gasping pt.- No history, treatment always precedes diagnosis.
KEY
POINTS

19. THE LEADING QUESTION
Leading question is that which suggests its answer, usually as yes or
no.
Leading questions lead to diagnosis.
These questions to be asked to pts. who do not give a cohesive
history.
Answers to these questions to cross verified, about their reliability
Often the pt. replies in yes, to emphasise his complaints
& replies in NO if he wants to hide some points.

20. FROM WHOM HISTORY TO BE COLLECTED
1.Only the patient in ordinary situations.
2.Interference by relatives to discouraged .
3.Children- Parents, preferably the mother.
4.Unconcious Pt- persons who were present at the onset of
illness
5.Transient loss of consciousness- TIA,Epilepsy – Eye
witness
6.Mental retarded/Deaf & Dumb- Care- takers

21. OBSERVATION OF NVC
NON-VERBAL COMMUNICATIONS
While the pt. is narrating his history
Observe pt. closely
- words he uses/emotional attachment to the words
- movement of hand & body parts etc, should be noticed.
EXAMPLES
If the pt. is weeping,signifies severity of pain- ANGINAL PAIN
Moving his hands over sternum- RETROSTERNAL IN SITE
Moving his hands over a wide area of abd.- ABDOMINAL PAIN
Points site of pain with finger- LOCALISED PAIN-PLEURISY
Groaning with abd. Pain- COLICKY PAIN
Cloth tied over head or abd. – HEADACHE OR COLICKY AB.PAIN
Talking in a loud voice- NERVOUS OR DEAF
Talking in low voice & looking at this side or other- SEX. PROBLEM
Wearing warm dress in summer- FEVER
Unable to complete a sentence in one breath- low VC
Giving extensive details of illness/t/t - HYPOCHONDRIAC

24. FOR SUCCESSFUL HISTORY TAKING
LIKE ANY OTHER ART ,PRACTICE MAKES A MAN
PERFECT
SO ALSO IN THE ART OF HISTORY TAKING ONE HAS TO
PRACTICE DAILY TO IMPROVE.
THE MORE ONE FEELS FOR THE PATIENT, THE MORE HE
GETS INVOLVED WITH HIM , THE MORE HE EXTRACTS
INFORMATIONS FROM HIM (PATIENT)
SENSE OF FEELING & INVOLVEMENT WITH THE PATIENT
IS THE SOLE CRITERIA FOR A SUCCESSFUL HT.

25. KEY ELEMENTS
•Introduce your self (name and position)
•Make a rapport with patient
•Beginning: ‘ Tell me what brought you to
hospital’
•Middle stem : Follow structured format
•End: Summarise and ‘Have you got
anything else to add or say?’

26. First Impressions
•Positive Impression
–Appearance
–Confidence
–Demeanor
–Body Language

27. Session Structure
1.Personal Information 5min
2.Chief complaints 10min
3.History of present illness 10min
4.History of Past Illness 10min
5.Systemic enquiry 10min
6.Family history 10min
7.Drug & Treatment history 10 min
8.Social history
9. Others 10min

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28. . 1.Personal Information1.Personal Information
•Always record personal details:
–Name,
–Age,
–Address,
–Sex,
–Ethnicity
–Occupation,
–Religion,
–Marital status.
–Date of examination
–ASK WHETHER PT IS CASH OR CREDIT
–REFD. BY WHOM

29. Personal Information
: Age
•Elderly:-
•Dementia
•Osteoarthritis
•Cornary
•Cataract
•Malingnancies
•Chronic lymphatic Leukaemia
•Multiple myeloma

30. Personal Information
Age:
Children
1.Congenital:-
Coarctation
Bicuspid AV
2. Inborn errors of Metabolism
3.Nutritional deficency:
Kwashiorkor, Marasmus, Vit.A Def.
4.Other Common Problems:
FB in ENT
5.Bleeding PR-Rectal polyp

31. Personal Information
Sex:
•Important factor towards the causation of disease:
–In Females:
»Endocrine disorders
»Rheumatoid, SLE, Collagen diseases
In Males:
Transmitted as x-linked
Haemophilias
Colour blindness
Gout due to def. in HGPRT enzyme.
Duchenne type muscular dystrophy
Smoking & alcohol – Multiple Myeloma

32. Personal Information
Locality
•Environmental factors:
–Dis. Related to Genetic constitution
Chaga’s disease: Brazil, Argentina, Uruguay
Sleeping sickness: Central & West African
Thalassaemia : Mediterranean countries.
Multiple sclerosis &
Sub.ac combined degn Temperate Climate
Of Spinal chord &
Pernicious anaemia :
Carcinoma stomach : Japan

33. Personal Information
Locality
•Khangri cancer : kashmir
•Goitre : Sub- Himalayan – largest belt in world
•Fluorosis : A.P,TN,Punjab, Harayana,Karnataka
•Kalazar :Bihar & WB
•Dracunculosis : Rajasthan
•Bancroftian filariasis : Orissa, AP,TN,kerala.

34. Personal Information :Occupation
•Pneumoconiosis
•Silicosis(silicon dusts) sand blasting , ceramic industry .
•Anthracosis (Coal workers)
•Asbestosis (Asbestos workers)
•Byssinosis (Textile workers)
•Brucellosis : Vetenarians
• Anthrax : carrying animal skins on their back.
• Leptospirosis : Sewerage workers
•Lead toxicity : Lead industries
Hypoplastic Anaemia : Exposure to Benzene chemicals.
Hypopalstic anaemia / leukaemia :Prolonged exposure X-Rays
Psittacosis and ornithosis. Bird handlers

35. 2.Chief Complaints & History of Present
Illness
•The C/C are complaints that brings the pt. for medical help.
•U can suggest a few words or phrases to the pt. so that
becomes meaningful.
•All c/c should be recorded chronologically.( as all symp.
May be manifestations of 1 illness at diff. stages or related
to the other as a cause & effect.
•Usually a single symptom, occasionally more than one
complaints eg: chest pain, palpitation, shortness of breath,
ankle swelling etc
•The patient describe the problem in their own words.
•It should be recorded in pt’s own words.
•What brings your here? How can I help you? What seems to
be the problem?

36. History of Present Illness - Tips
•Elaborate on the chief complaint in detail
•Ask relevant associated symptoms
•Have differential diagnosis in mind
•Lead the conversation & thoughts
•Decide & weigh the importance of minor
complaints

37. History of Present Illness - Tips
•Avoid medical terminology & make use of a
descriptive language that is familiar to them
•Ask OPQRSTA for each symptom

38. Pain (OPQRST)Pain (OPQRST)
Position/site
Severity – how it affects daily work/physical activities. Wakes
him up at night, cannot sleep/do any work.
Relationship to anything or other bodily function/position.
Radiation: where moved to
Relieving or aggravating factors – any activities or position
Quality, nature, character – burning sharp, stabbing, crushing; also
explain depth of pain – superficial or deep.
Timing – mode of onset (abrupt or gradual), progression
(continuous or intermittent – if intermittent ask frequency/
nature.)
Treatment received or/and outcome.
Onset of disease
Are there any associated symptoms? .

39. Chief Complaints
•EXAMPLE 1.
•A patient may come for haemoptysis (say for 2
days), but he fails to tell that he was having cough
for two months.
•Alarming symptom: Haemoptysis
Here the cough hasn’t been complained by the patient, it
has been extracted from him.
His C/C : Cough- 2 m, Haemoptysis – 2 days
Pulmonary tuberculosis: Bronchogenic carcinoma

40. EXAMPLE 2.
•Case 2- Haematemesis – 2days
•On further asking it was revealed that having
fever with joint pain – 5 days
•Illness started with fever with joint pain
•To get relief took analgesics – erosive gastritis-
•Haematemesis
•Therefore – haematemesis is not a part of
original illness , but is a complication of t/t

41. True complaints
•Fever -5 days
•Joint Pain – 5 days
•Haemetemesis – 1 day
•Sometimes pt may c/o D yspnoea at rest &
•Palpitation – 5 days
•But on enquiry it was revealed that he is
having dyspnoea since 5 yrs
•Dyspnoea – 5yrs/ DAR- 5d/ Palpitation-5d

42. THE STARTING COMPLAINT
•Always emphasis should be given to collect the
correct starting complaint.
•What was the 1
st
comp.when the pt. felt unwell.
•With the progress of the illness, more & more
symptoms get added to the starting complaint.
•Eg: Unconscious pt. with fever & neck rigidity
•- meningitis or S.A haemorrhage
•If 1
st
cc is Severe headache – S.A.H
•If 1
st
cc is Fever -Meningitis

43. THE STARTING COMPLAINT
•Ex: 2
•A woman with advanced Preg.+Convulsions+LOC
•Fever on O/E ( Eclampsia or Encephalitis)
•Episodic convulsions+ High BP – Fever- ECLAMPSIA
•1
st
C/C is Fever , then Convulsions – Encephalitis

44. Duration of illness: Tips
•Exact duration of illness
• if in months & years –onset is gradual –chronic problem
• if in days / hrs- onset is sudden – acute problem
• if episodic – epilepsy, bronchial asthma,CCF, AE of COPD
•OTHER PERTINENT POINTS:
•For how long you are ill.
•When you were completely normal.
•Is this complain for the first time or you have other episodes.

45. Ascertaining the Genuine nature of complaint
•Always try to verify whether c/c is genuine or not.
• Convulsions-
•Do not get confused with restlessness + abnormal limb
movements
•Associated features-tongue bite,involuntary passage of
urine,twisting of the head,rolling of eye ball
•BREATHLESSNESS
•If a man doing physical labour complains of
breathlessness its genuine nature can be verified by
asking how much effects his work.
•No more able to work, genuine.

46. Ascertaining the Genuine nature of complaint
•Weight loss
•Often people exaggerate the complaint of weight loss.
•This is not always acceptable or believable.
•Ask the patient, what was previous weight and when it
was recorded ?
•From the present weight you can calculate the weight
loss over that period.
•This can also be assessed fairly well from the clothing.
•Once significant weight loss is established, very likely
there is a genuine illness.

47. •Appetite
•Frequently patients complain of loss of appetite.
•Ask th person who serves food to him.
•What is his usual food habit (quantity and quality)
any change or not in this habit can be ascertained
from them.
•Vomiting
•Fictitious vomiting.
•He might be bringing out little amount of saliva
might be retching only.
•Ask the pt. to collect all the vomitus and produce
before you.
Ascertaining the Genuine nature of complaint

48. •Fever and Chill
•Record the temperature.
•Type of fever - intermittent.. Continuous or chills
Administration of antipyretics.
•Maintain a temperature chart at least four to six times
a /week
•Then proceed for investigation.
•Remember that if there is recorded fever in
any case, there is an organic illness.
Ascertaining the Genuine nature of complaint

49. •Haemoptysis and Haematemesis
•Confusion,cough,nausea,vomiting,melaena,colour of blood
presence or absence of clot or food metarial, froth will help
to decide.
•Amount of blood loss.
•Absence of melaena.
•Poisoning
•Always assess the amount of poison consumed from the
physical signs.
•The time gap between the intake and examination
•Vomited after intake time.
•Intake of the poison and gastric lavage.
•Received any treatment period.
Ascertaining the Genuine nature of complaint

50. •The details of the circumstance under which the
illness started will give valuable clue to the
diagnosis.
•Diabetes mellitus - hypoglycemic coma
• Malaria endemic area few days Delhi epidemic
-dengue fever.
Circumstances under which the Disease Started

51. •More than one complaint told by the patient gets
frankly revealed by tactful questioning.
•These associated complaints help maximum in
reaching at the diagnosis.
Associated Complaints

52. QUESTION & ANS. SESSIONS
Question ?
1.Fever associated with cough and expectoration ?

53. Answer
1.Respiratory infection.

54. Question
2. Fever associated with dysuria and frequency ?

55. Answer
2. Urinary tract infection.

56. Question
3.Fever associated with jaundice ?

57. Answer
3.Hepatobiliary disorder, leptospirosis
complicated malaria.

58. Question
4.Fever associated with loss of consciousness?

59. 4.Cerebral malaria,meningitis,encephalitis.
Answer

60. 1. Swelling of the body associated with dyspnoea?
Swelling of the body
Question

61. Answer

1.Congestive heart failure, angioneurotic oedema.

62. Question

2. Swelling of the body associated with jaundice?

63. Answer
1. Subacute hepatic failure, decompensated cirrhosis.

64. Question
3. Swelling of the body associated with oliguria and
haematuria?

65. 1. Acute glomerulonephritis.
Answer

66. 1.Breathlessness associated with chest pain?
Breathlessness
Question

67. 1.Pneumothorax,pulmonary embolism,acute
myocardial infarction.
Answer

68. Question
2 . Breathlessness associated with wheezing?

69. Answer

2. Bronchial asthma.

70. Question
3 . Breathlessness associated with cough and sputum
production?

71. Answer
3 . Chronic bronchitis.

72. 4 . Breathlessness associated with hemoptysis?
Question

73. 4 . Mitral stenosis, pulmonary infarction.
Answer

74. 1. Joint pain associated with morning stiffness?
Joint pain
Question

75. Answer

1 . Rheumatoid arthritis.

76. Question
2 . Joint pain associated with high fever?

77. 2 . Septic arthritis.
Answer

78. •Significant negative history should be told in
relevant cases.
•Unconscious patient complete absence of fever
exclude infective condition.
•Absence of syncope angina aortic valve disease,
convulsion, absence of head injury and
intoxication should be mentioned.
•Ascending paralysis -absence of animal bite.
Negative History

79. •Effect relationship with present illness.
•Guide the treatment of the present illness.
•History of similar illness.
•History of significant illness.
•Hypertension, diabetes mellitus, tuberculosis and
syphilis should be included as these conditions
can affect many organs.
History of Past illness

80. •Ask the patient or his relatives to enumerate all
the major illnesses he has suffered from childhood
including major accidents and surgeries. From
them one has to screen out which is important
which is not.
•Produce the documents related to previous illness.
•The patient given history example - rheumatic
fever, what age it occurred, joints were affected,
how severe was the joint pain, fleeting penicillin
prophylaxis.
History of Past illness

81. •Symptoms like polyuria, polyphagia and
polydipsia.
Collecting History of Diabetes Mellitus

82. •Previous treatment records, X-rays, sputum
examination reports.
•Previous history of prolonged fever, persistent
cough, hemoptysis, weight loss.
•The drugs prescribed antitubercular drugs.
Collecting History of Tuberculosis

83. •In a country like india history of hypertension is
obtained in a confusing manner.
•Like reeling of head.
•Always emphasis should be given to produce the
documentary evidence of hypertension.
•Names of the drugs.
•If a normal recording of blood pressure is found
always ascertain whether the patient is no the
drugs or off the drugs.
History of Hypertension

84. •Syphilis in earlier days was the single most
important disease to involve almost all organs.
•Primarily it is a sexually transmitted disease.
History of STD
•AIDS- History contact
- Blood Transfusion
- Any injection pride

85. •Certain diseases are likely to occur in many
members of the family.
•Genetically transmitted diseases.
•Familial clustering of diseases.
6.Family History

86. Family History
•Any familial disease/running in families e.g.
breast cancer, IHD, DM, schizophrenia,
Developmental delay, asthma, albinism.
•Infections running in families as TB, Leprosy.
•Cholera, typhoid in case of epidemics.

87. •There are many diseases which are transmitted
genetically.
•Genetically transmitted condition can occur in a
person without similar illness in the family due to
mutation.
•A particular condition may not express completely
in all cases (full expression or partial expression).
•History of consanguineous marriage the family
Genetically Transmitted Disease

88. •Adult polycystic kidney disease
•Multiple neurofibromatosis.
•Hereditary spherocytosis.
•Familial hypercholesterolemia.
•Acute intermittent porphyria and so on.
Autosomal Dominant Disorders

89. •Albinism
•Wilson’s disease
•Sickle cell anaemia
•Beta thalassaemia
•Cystic fibrosis
Autosomal Recessive Disorders

90. •Haemophilia
•G6PD deficiency
•Colour blindness
X-Linked Recessive Disorders

91. 9. Personal/ Social History
•Food Habits
•Malnutrition allergy or intolerance.
•Excess of coffee -Reflux oesophagitis
•Excess of tea - Supraventricular ectopics
•Vegetarian -vitamin B12 deficiency
•Dietary toxins with Khesari dal -(Lathyrism)

92. Social & Personal History
•Smoking history - amount, duration & type.
• A strong risk factor for IHD
•Alcohol history - amount, duration & type.
•Occupation, social & education background, ADL, family social
support& financial situation.
•Social class.
•Home conditions as:
•Water supply.
•Sanitation status in his home & surrounding.
•Animals / birds in his/her house.

93. Social History: smoking
•The most important cause of preventable diseases.
•Smoking history - amount, duration & type.
• Amount: pack”year calculations.
•Duration: continuous or interrupted.
•Any trials of quitting & how many.
•Deep inhalation or superficial.
•Active or passive smoker.
•Type: packs, self-made, Cigars, Shesha , chewing etc.

94. Addiction and Habituation
•Alcohol
•GI system – gastritis, pancreatitis, fatty liver,
hepatitis, cirrhosis of liver, the nervous system,
peripheral neuropathy, Korsakoff’s psychosis,
cerebellar degeneration, dementia.
•Smoking – Chr.Bronchitis, Broncho.Ca.,CAD,
•Gudakhu
•Oral tobaco – oral cancer

95. •Opium – Constipation
- Do not respond to analgesics and sedatives.
•Drugs- Narcotics and benzodiazepines abuse
•Sleep
–Insomnia – unfavourable environment
-Physical illness, orthopnoea, or any painful
condition
•Excessive sleep – Alcohol, sedatives, hypothalamic,
disorders, Pickwickian syndrome.
•Reversal sleep Rhythm (night time insomnia & day time
somnolence – old age

Addiction and Habituation

96. Bowel and Bladder
Recent change in Bowel habits – Colorectal.ca
Recent onset of diarrhoea – infective
BLADDER HABITS
- Women evacuate bladder less frequently than males.
-Disturbances in bladder habit takes several forms like
-Increased frequency of urination, polyuria, oliguria,
hesitancy, urgency, dysuria, incontinence, retention, etc.

97. Socioeconomic Status
• Poor SES status – Various infection, infestations,
nutritional def.
•High SES status – sedentary lifestyle, obesity & related
problems.

98. 7.Drug & Treatment History
•Drug History (DH)
•Always use generic name or put trade name in brackets with
dosage, timing &how long.
•Example: Ranitidine 150 mg BD PO
• Note: do not forget to mention:
OCT/Vitamins/Traditional /Herbal medicine & alternative
medicine
•Blood transfusion.
•ALLERGY OR SENSITIVE DO DRUGS.
•ANY T/T OR SURGERY

99. Menstrual & obstetrics HistoryMenstrual & obstetrics History
•Gyn/Obstetric history if female
•Gravida, para, abortions, C- sections, antenatal
care & screening for Hep B & C.
•Menarchy & Menopause
•Menstrual cycles
•LMP

100. Other Relevant HistoryOther Relevant History
•Immunization if small child
•Note: Look for the child health card.
•Travel / sexual history if suspected STDs or infectious
disease
•Note:
•If small child, obtain the history from the care giver.
Make sure; talk to right care giver.
•If some one does not talk to your language, get an
interpreter(neutral not family friend or member also
familiar with both language).
•Ask simple & straight question but do not go for yes or
no answer.

101. System Review (SR)System Review (SR)
This is a guide not to miss anything
Any significant finding should be moved to HPC or
PMH depending upon where you think it belongs.
Do not forget to ask associated symptoms of Present
Complaints with the System involved
When writing up patient notes, record the systems
review so that the relieving doctors know what system
you covered.

102. System ReviewSystem Review
General
•Weakness
•Fatigue
•Anorexia
•Change of weight
•Fever/chills
•Lumps
•Night sweats

103. System ReviewSystem Review
Cardiovascular
•Chest pain
•Paroxysmal Nocturnal Dyspnoea
•Orthopnoea
•Short Of Breath(SOB)
•Cough/sputum (pinkish/frank blood)
•Swelling of ankle
•Palpitations
•Cyanosis

104. System ReviewSystem Review
Gastrointestinal/Alimentary
•Appetite (anorexia/weight change)
•Diet
•Nausea/vomiting
•Regurgitation/heart burn/flatulence
•Difficulty in swallowing
•Abdominal pain/distension
•Change of bowel habit
•Haematemesis, melaena, haematochezia
•Jaundice

105. System ReviewSystem Review
Respiratory System
•Cough(productive/dry)
•Sputum (colour, amount, smell)
•Haemoptysis
•Chest pain
•SOB/Dyspnoea
•Tachypnoea
•Hoarseness
•Wheezing

106. System Review System Review
Urinary System
•Frequency
•Dysuria
•Urgency/strangury
•Hesitancy
•Terminal dribbling
•Nocturia
•Back/loin to groin pain
•Incontinence
•Character of urine: colour/ amount (polyuria)
& timing
•Fever

107. System Review System Review
Nervous System
•Visual/Smell/Taste/Hearing/Speech problem
•Headache
•Fits/Faints/Black outs/loss of consciousness
•Muscle weakness/numbness/paralysis
•Abnormal sensation
•Tremor
•Change of behaviour or psyche.
•Paresis.

108. System Review System Review
Genital system
•Pain/ discomfort/ itching
•Discharge
•Unusual bleeding
•Sexual history
•Menstrual history – menarche/ LMP/
duration & amount of cycle/
Contraception/ menopause/PMB
•Obstetric history – Para/ gravida/abortion

109. System Review System Review
Musculoskeletal System
•Pain – muscle, bone, joints
•Swelling
•Weakness/movement
•Deformities
•Gait

110. SOAPSOAP
Subjective: how patient feels/thinks about him. How does
he look. Includes PC and general appearance/condition of
patient
Objective – relevant points of patient complaints/vital
signs, physical examination/daily weight,fluid
balance,diet/lab. investigation and interpretation
Plan – about management, treatment, further investigation,
follow up and rehabilitation
Assessment – address each active problem after making a
problem list. Make differential diagnosis.

111. SUMMARY
1.PERSONAL INFORMATION
2. CHIEF COMPLAINTS
3.HISTORY OF PRESENT ILLNESS
4.HISTORY OF PAST ILLNESS
5.FAMILY HISTORY
6.PERSONAL /SOCIAL HISTORY
7. DRUG & TREATMENT HISTORY
8.MENSTRUAL & OBTETRICS HISTORY
9.SYSTEMIC REVIEW
10.TO REACH APROVISIONAL DIAGNOSIS

112. ERROR IN HISTORY TAKING
Wrong or incomplete history
Improper sequence of history taking
Identification of malingering
Ignoring the family & Relatives
Not maintaining privacy

113. Biggest medical
mistakes

114. The Andrews Family

116. When in an in vitro
fertilization centre ..

117. The wrong sperm was
inseminated!!!

118. Jesica Santillan, 17

119. Died
two
weeks
after

120. Receiving incompatible heart and lungs
during a transplantation

121. Benjamin Houghton
47-year-old Air Force veteran

122. Got his healthy right testicle
mistakenly removed in a case of a
wrongful operation

123. Failure on the part of
medical personnel to
mark the proper
surgical site before the
procedure, spurred a
$200,000 lawsuit from
Houghton and his wife.

124. Donald Church, 49

125. Arrived at the University of Washington Medical
Center to get his tumor removed
On leaving, his tumor was gone, but

126. But a 13’’ metal retractor had
taken its place!!

127. Joan Morris, 67
admitted to a
teaching hospital for
cerebral
angiography

128. mistakenly underwent an invasive
cardiac electrophysiology study!

129. she was taken for a open heart
procedure and operated for an
hour!!

130. Doctors had
made an
incision in
her groin,
punctured
an artery,
threaded in
a tube and
snaked it up
into her
heart!!!

131. Only when her consulting doctor
informed the team on phone, did they
sent her back to her ward in stable
condition

133. operated on the wrong side of an 82
year old patient's head

134. Not Once
Not Twice

135. Willie King
got his
wrong leg
removed in
an
amputation
operation

136. The surgeon's
team realized
in the middle
of the
procedure
that they
were
operating on
the wrong leg

137. Park Nicollet Methodist
Hospital

138. Removed the healthy kidney of a
patient who came for a kidney tumor
operation

139. Raleigh General Hospital
in Beckley

140. Performed an abdominal
surgery on a 73 year old
patient

141. Without administering
general anesthesia!!

142. The patient could feel every slice of
the doctor’s scalpel and..
Committed suicide in a state of trauma

143. Dana
Carvey, the
well known
American
comedian
and actor

144. Got his wrong artery bypassed

145. And thus filed a $7.5 million lawsuit
against the doctor

147. SO WHAT HAVE WE DECIDED ?
OUR RESOLUTION 2013

148. GOOD HISTORY
TAKING IS
ABSOLUTELY
NECESSARY TO
MAKE AN
EXCELLENT
PHYSICIAN
SO TODAY OUR DECISION IS:

150. WE SHOULD ALWAYS BE A CARING DOCTOR
THANK YOU ALL