Medical-History-Taking-A-Comprehensive-Guide (1).pdf

Medical history taking steps explained

1. Medical History
Taking: A
Comprehensive
Guide
Medical history taking is a crucial component of patient care. It involves
gathering detailed information about a patient's health and medical
experiences to help provide accurate diagnosis and treatment.
by Kashir Ahmad

2. Greetings and Introduction
1
Initial Greeting
Begin by greeting the patient politely and introducing
yourself, stating your role.
2
Establish Rapport
Create a comfortable and trusting environment for the
patient to share their medical history openly and honestly.
3
Explain Purpose
Clearly explain the purpose of the medical history taking
process and reassure the patient that their information is
confidential.

3. BioData: The Foundation
1
Basic Information
This includes the patient's
name, age, sex, address,
phone number, and
occupation.
2
Identifying Information
This helps to distinguish
patients, ensure accurate
record-keeping, and
facilitate communication.
3
Health History Clues
Certain demographic factors, like age or occupation, can provide
insights into potential health risks or predispositions.

4. Obtaining the Chief
Complaint
1
Patient's Own Words
Encourage the patient to describe their main concern in their
own words.
2
Clarifying Questions
Use open-ended questions to understand the nature and
duration of the complaint.
3
Objective Details
Record the complaint using specific, objective terms,
avoiding vague language.

5. History of Present Illness and Systemic Review
History of Present Illness
A detailed account of the patient's symptoms, including
onset, progression, and any relevant factors.
Systemic Review
A comprehensive review of each body system, inquiring about
any symptoms or concerns in each area.

6. Past Medical, Surgical, Drug,
and Allergic History
Past Medical History Previous diagnoses, treatments,
hospitalizations, and chronic
conditions.
Surgical History Past surgical procedures, dates,
and complications.
Drug History Current medications, dosage,
frequency, and any past
medication use.
Allergic History Allergies, including reactions,
severity, and types.

7. Personal Habits
Dietary Habits
Inquire about the patient's
typical diet, including
frequency and types of
meals, snacking patterns, and
dietary restrictions.
Exercise Routine
Understand the patient's
physical activity level, type,
frequency, and duration of
exercise.
Smoking Status
Ask about the patient's
smoking history, including
pack-years, quit attempts,
and current status.
Alcohol Consumption
Inquire about the patient's
alcohol use, including type,
frequency, and amount
consumed.

8. Socioeconomic Status
Financial Situation
Understanding a patient's
financial resources can help
tailor treatment plans and
suggest affordable options.
Social Support Network
Assessing the patient's family,
friends, and community
connections provides insights
into their social well-being.
Living Conditions
Inquiring about housing, access to basic necessities, and
environmental factors can reveal potential health risks.