History Taking final.ppt( all courses history taking)

This slide contains information regarding history taking in a hospital it involves demographic data, presenting complaints, history of presenting complaints and so many, it's a guide on how you ask the patient appropriate questions for you to reach out to the diagnosis

2. Why do we take history from
the patient?

3. What would happen
if we do not make a diagnosis?
or
if we made the wrong diagnosis?

4. How do we take history?

5. In the outpatient clinic
In the inpatient clinic

6. The present complaint
The history of the
present complaint
Remaining questions of
abnormal system
Review of systems
Past medical history
Past surgical history
Drug history
Immunizations
Family history
Social history &
habits

7. INTRODUCE YOURSELF TO THE
PATIENT AND EXPLAIN TO HIM OR HER
WHAT YOU ARE GOING TO DO.
GET A CHAPERON WHEN YOU
INTERVIEW A FEMALE PATIENT.

8. Name
Age
Sex
Marital status
Occupation
Address
Date of interview

9. In patient’s own words with duration.
“What are you complaining of?”
“What is the problem?”
“What is the matter?”

10. EXAMPLE: ABDOMINAL PAIN
Site
Time and mode of onset
Nature
Duration
Severity
Radiation
Progression/end
Relieving factors
Exacerbating factors
Cause

12. What is a diagnosis?

13. Any diagnosis consists of
Anatomical part + Pathological part
Examples:
Breast cancer
Peptic ulcer
Fracture femur

14. Most likely why?
Less likely why?
Least likely why?

15. The Gastro-intestinal system
The Respiratory system
The Cardiovascular system
The Urogenital system
The Nervous system
The Musculoskeletal system

16. Appetite
Diet
Weight
Teeth and taste
Swallowing
Regurgitation
Fatulance
Heartburn
Vomiting
Haematemesis
Abdominal PAIN
Abdominal distension
Defecation
Change of color of skin

17. Cough
Sputum
Haemoptysis
Dyspnoea
Orthopnoea
Chest pain

18. CHEST PAIN
Dyspnoea
Orthopnoea
Palpitations
Cough and sputum
Dizziness and headache
Ankle swelling
Peripheral vascular symptoms

19. Pain
Oedema
Thirst
Micturition
Urine
Scrotum and urethra
Menstruation
Pregnancies
Breasts
Secondary sex
characteristics

20. Mental state
Conscious level
Fits
TIAS= transient ischemic attacks
Loss of sensations
Paraesthesiae (pins and needles)

21. Pain
Swelling
Limitation of movements of any joint

22. Any hospitalization
TB = Tuberculosis
DM = Diabetes mellitus
Asthma
Rheumatic fever
Contact with patients with hepatitis or aids

23. Previous operations
Blood transfusion
Any complications with anesthesia
Bleeding tendencies

24. Steroids
Insulin
Antihypertensive drugs
Hormone replacement therapy

25. DPT = diphtheria, pertussus, tetanus
Measles
Mumps
Rubella
Poliomyelitis
TB
Smallpox
Typhoid

26. Health and age or cause of death of patient’s
parents ,brothers and sisters

27. Marital status
Hazards of occupation
Social status-type of residence
Travel abroad-dates
Smoke
Drinks
Any unusual?

28. Patient’s name, age and sex.
Complaint and the most important positive
characteristics of his/her complaint
The most important negative features of his
complaint.

29. Review the list you made earlier

30. To make a diagnosis
To formulate a complete pictureabout this
patientwhich will enable you to plan his or
hermanagement