1 / 32

Principles of history taking

oshin
Download Presentation

Principles of history taking

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

    1. Principles of history taking

    2. Reviewing the Chart: The medical chart give you valuable information about past diagnosis and treatment You should look at the identifying data (age, gender, address, marital status, health insurance, the medication list, the documentation of allergies)

    3. Clinician’s Behaviors As you observe the patient throught the interview, the patient will be watching you You should be sensitive to those messages and manage them as well as you can Posture, gesture, eye contact, and words can express interest, attention, acceptance, and understanding The skilled interviewer seems calm and unhurried, even when time is limited

    4. Clinician’s Appearance

    6. Learning about the Patient’s iIlness Greeting the Patient Greet the patient and introduce yourself by name If this is the first contact, clarify your role, such as stating your status as a student and explaining your relation to the patient’s care When other individuals are present, ask the permission of the patient to conduct the interview in front of them

    7. The Patient’s Comfort

    8. Comprehensive history Data and time of history: the date is important Identifying data: including age, gender, maritual status and occupation Source of history: such as patient, family, friend, officer, consultant, medical record Chief complaints

    9. Comprehensive history Present illnes Current medication: including dose and frequency of use Allergies Past history Childhood illnesses: such as measles, rubella, mumps, whooping cough, chicken pox, rheumatic fever, polio

    10. Comprehensive history Adult illnesses: Medical Diabetes mellitus Hypertension Hepatitis Asthma HIV

    11. Comprehensive history Adult illnesses: Surgical: include dates, indication, outcome Obstetric/ Gynecologic: inculde obstetric history, menstruation history, birth control, number and gender of partners, at-risk practises Psychiatric: include dates, diagnosis, hospitalisations, treatment

    12. Current health status Tobacco (type used, amount and duration of use) Alcohol (type used, amount and duration of use) Drugs (type used, amount and duration of use)

    13. Current health status Exercise and diet Immunisations: Tetanus Pertussis Diphteria Polio Measles Rubella Mumps Influenza Hepatitis B

    14. Family history Age and health, or age and couse of death of each immediate family members (parents, siblings, spouse, and children) Date of grandparents and grandchildren may also be useful

    15. Family history Diabetes mellitus Heart disease Hypercholeterolemia High blood pressure Stroke Kidney diseases

    16. Family history Arthritis Anemia Allergies Asthma Headaches Mental illness

    17. Family history Tuberculosis Cancer Drugs Epilepsy

    18. Personal and Social History Occupation and education Home situation Daily life Leisure activites/hobbies

    19. Present illness The principal symptoms should be discribed in terms of: Location Quality Quantity and severity Timing Factors that have aggrevated or relieved them

    20. Review of systems General: Weight, recent weight change Weakness Fatique Fever

    21. Review of systems Skin: Rashes, lumps, sores, itching, dryness, color change Hair and nails changes

    22. Review of systems Head: headache, head injury, dizziness Eyes: vision, glasses, contact lenses, pain, redness, dryness, double vision, spots, flashing lights, glaucoma, cataracta Ears: hearing, vertigo Nose an sinuses: frequent cold, nasal stuffiness, hay fever, sinus trouble

    23. Review of systems Mouth and throut: condition of teeth, gums, bleeding gums,sore tonque, dry mouth, frequnt sore throats, hourseness Neck: lumps, „swollen glands”,goiter pain Breast: lumps, pain and discomfort Respiratory: cough, sputum (color quantity) hemoptysis, dyspnea, wheezing, asthma, bronchitis, emphysema, pneumonia, tuberculosis,

    24. Review of systems Cardiac: heart trouble, high blood pressure, rheumatic fever, heart murmurs, chest pain or discomfort, palpitations, dyspnoe, orthopnoe, paroxysmal nocturnal dyspnoe, edema

    25. Review of systems Gastrointestinal: Trouble swallowing Heartburn Appetite Nausea Vomiting Regurgitation Vomiting of blood

    26. Review of systems Gastrointestinal: Bowel movements Color and size of stools Change of bowel habits Rectal bleeding Black tarry stools Hemorrhoids Constipation Diarrhea

    27. Review of systems Gastrointestinal: Abdominal pain Food intolerance Jaundice Liver or gallbladder trouble hepatitis

    28. Review of systems Urinary: Frequency of urination Polyuria Nocturia Burning or pain on urination Hematuria Urgency Reduces caliber or force if the urinary stream Incontinece stones

    29. Review of systems Genital: Female: Age at menarche Regularity Frequency Duration of periods Amount of bleeding Last period

    30. Review of systems Genital: Femal: Dysmenorrhea Premenstrual tension Age at menopausa Itching Sexually transmitted diseases Number of pregnanycies Number and type of delivery Number of abortion

    31. Review of systems Genital: Male: Hernias Testicular pain Sexually transmitted diseases

    32. Review of systems Periferla vascular: Intermitten claudication Leg cramps Varicose veins Past clots in the veins

    33. Review of systems Musculoskeletal: Muscle pain, weakness Joint pain Stiffness Arthritis Gout Backache

    34. Review of systems Neurologic: Seizeres Weakness Paralysis Numness or loss of sensation Tremor

    35. Review of systems Hematologic Anemia Easy bruising or bleeding Past transfusion

    36. Review of systems Endocrine Thyroid trouble Heat or cold intolerance Excessive sweating Diabetes Excessive thirst or hunger polyuria

    37. Establishing Rapport The initial contact with the patient sets the foundation for the relationship Good interviewing technique allows patients to recount their own stories spontaneously You should listen actively and watch for clues to important symptoms, emotions events, and relationships You can than guide the patient into telling you more about the areas that seem most significant. This is done by using direct questioning Questionts should proceed from the general to the specific

    38. Sometimes patients seem quite unable to describe their symptoms without help Offer multiple-choice answers” Is your pain aching, sharp, pressing, burning, shooting, or what? Use lanquage that is undestandable and appropiate to the patient Establishing the sequence and time course of the patient’s symptoms is important You can encourage a chronologic account by such questions as” What than?” or „What happened next?”

    39. Generating and Testing Diagnostic Hypotheses As you learn about the patient’s story and the symptoms, you should be generating hypotheses about what body systems might be involved by a pathologic process For example, leg pain, suggests a problem in the peripheral vascular, musculoskeletal, or nervous system

    40. 1. Its location.Where is it? Does it radiate? 2. Its quality. What is it like? 3. Its quantity or severity. How bad is it? 4. Its timing. When did or does it start? How long does it last? How often does it come? 5. The setting in which it occurs, including enviromental factors, personal activities, emotional reactions. 6. Factors that make it better or worse.

More Related