HISTORY TAKING
Dr.Moeen-uz-zafar
HEADLINES
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PATIENTS DATA
PRESENTING COMPLAINTS
HISTORY OF PRESENTING COMPLAINTS
SYSTEMIC REVIEW
PAST HISTORY
PERSONAL HISTORY
FAMILY HISTORY
SOCIOECCONOMIC HISTORY
PATIENTS DATA
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NAME
AGE
SEX
OCCUPATION
ADDRESS
RELIGION
DATE/TIME/MODE OF ADMISSION
PRESENTING COMPLAINTS
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The Complaints which bring the patient to
the doctor
Recorded in chronological order
e.g
Abdominal pain …. 3 days
Vomiting …. 2 days
Fever ………. 1 day
Use patients own words
No leading Questions
Recurrent symptoms can be recorded
HISTORY OF PRESENTING
COMPLAINTS
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Symptoms are recorded in detail
Always try to search when the
patient was totally all right
DESCRIPTION OF SYMPTOMS
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PAIN
SITE
INTENSITY
RADIATION
SHIFT
REFERRED PAIN
DURATION
CHARACTER e.g burning, aching, colicky, stabbing e.t.c
PERIODICITY
SPECIAL TIME OF OCCURANCE
AGGRAVATING FACTORS
RELIEVING FACTORS
ASSOCIATED PHENOMENA
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FEVER
MODE OF ONSET
RIGORS
GRADE
36.6 – 37.2 C
HYPERPYREXIA.. > 41.6
HIGH GRADE .. > 39
LOW GRADE .. > 38.5
HYPOTHERMIA .. < 35
PATTERN
CONTINUOUS
REMITTENT
INTERMITTENT
QUOTIDIAN
TERTIAN
QUARTAN
RELAPSING
UNDULATING
STEP LADDER
ASSOCIATED FEATURES
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WEIGHT LOSS
HOW MUCH IS LOST
APPETITE
ASSOCIATED FEATURES e.g FEVER , NIGHT
SWEATS
MASS
DURATION
SITE
RECENT CHANGES
PAIN
FEVER
PRESSURE SYMPTOMS
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EDEMA
GEN/LOCAL
WHERE IT STARTED FIRST
OTHER FEATURES e.g SOB, CHRONIC
DIARRHEA, OLIGURIA
DYSPNOEA
(1) EXERTIONAL:
DURATION
ACTIVITY PPT.
PROGRESSION
PAROXYSMAL NOCTURNAL
ORTHOPNEA
H/O CHEST PAIN, RF
(2) DYSPNOEA AT REST (episodic)
AGE OF ONSET
FREQUENCY , SEVERITY and DURATION
OF ATTACKS
H/O ALLERGY
F/H OF ASTHMA
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PALPITATION
REST/EXERTION
DURATION
START OR TERMINATE GRADUALLY OR
SUDDENLY
ASSOCIATED SYMPTOMS e.g tremors,
heat intolerence
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COUGH
DURATION
FREQUENCY
SEVERITY
NIGHT or DAY
DRY or PRODUCTIVE
QTY, COLOUR and SMELL of
SPUTUM
HEMOPTYSIS
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VOMITING
DURATION
FREQUENCY
RELATION WITH FOOD
ANY SPECIAL TIMING
WT. LOSS
VOMITUS .. QTY, COLOUR , SMELL
HEMETEMESIS
MELENA
ASSOCIATED SYMPTOMS e.g int.
obst.
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DIARRHEA
DURATION
FREQUENCY
QTY OF STOOL
CONSISTENCY
BLOOD/MUCUS
HEMATOCHAZIA
TENESMUS
NOCTURNAL
ASSOCIATED SYMPTOMS
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CONSTIPATION
USUAL BOWEL HABITS
DURATION
BLOOD IN STOL
H/O ALTERNATING DIARRHEA
DRUG HISTORY
CHANGE IN EATING HABITS
OTHER SYMPTOMS
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DYSPHAGIA
DURATION
SOLID/LIQUID
PROGRESSIVE
SITE OF FOOD STICKING
PAIN IN SWALLOWING
( ODYNOPHAGIA)
LOSS OF WEIGHT
VOMIT … DOES IT CONTAIN OLD
FOOD PARTICLES
PAST H/O HEART BURN
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JAUNDICE
PAIN RT HYPOCH.
APPETITE
DISTASTE
COLOUR OF STOOL AND
URINE
ITCHING
WT LOSS
H/O OF BLOOD TRANSFUSION,
CONTACT
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HEADACHE
SITE
SEVERITY
DURATION
PROGRESSION
CONTINUOUS/INTERMITTENT
CHARACTER
TIMING e.g raised ICP
ASSOCIATED PHENOMENA
e.g HALO + RED EYE
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WEAKNESS/PARALYSIS
MONO/HEMI/PARAPLEGIA
COMPLETE( PLEGIA)
INCOMPLETE ( PARESIS )
ONSET
STATIC or PROGRESSIVE
LOSS OF CONSCIOUSNESS
FITS
SPEECH
H/O HTN , DM etc
F/H of vascular disease
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FITS/ CONVULSION
AGE OF ONSET
LOSS OF CONSCIOUSNESS
GEN/LOCAL
AURA
TONGUE BITE
FECAL/URINARY
INCONTINENCE
DURATION OF ATTACK
AFTER SYMPTOMS
SYSTEMIC REVIEW
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GENERAL appetite; weight; sleep
CVS SOB; palpitation; chest pain
RESP. Cough; sputum; hemoptysis
GIT nausea; vomit; abdominal pain; bowel habits;
dysphagia
UT flank pain; dysuria; frequency;
nocturia
NERVOUS SYSTEM weakness; headache;
fits
LOCOMOTOR joint pain; stiffness
ENDOCRINE polyuria; polyphagia; heat intolerence
EYE/ENT PROBLEMS
PAST HISTORY
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MEDICAL
SURGICAL
ALLERGIES
DRUG
SIMILAR HISTORY IN PAST
BIRTH HISTORY and VACCINATION
MENSTRUAL HISTORY
menarche
D/C
regularity
pain
intermenst./ post coital bleed
menopause
PERSONAL HISTORY
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DIET
ADDICTION
LIVING/WORKING CONDITION
SEXUAL HABITS
SPOUSE and CHILDREN
PREVIOUS OCCUPATIONS
FAMILY HISTORY
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MAKE A FAMILY TREE
ASK ANY FAMILY H/O HTN, DM etc
SOCIOECONOMIC CONDITION
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AVERAGE INCOME/ DEPENDENTS
SOCIAL ENVIRONMENT