HISTORY TAKING

WHY HISTORY TAKING IS IMPORTANT Certain diseases can only be diagnosed by a good history e.g angina pectoris, trigeminal neuralgia and migraine as there may be no physical sign . In most other diseases, history is the basis which guides physical examination and investigation leading to diagnosis.

GENERAL CONSIDERATIONS

1.Aims and objectives 2.Sources of history 3.Content of history 4.Techniques of history taking

Aims and objectives of history taking

1-To obtain an accurate account of complains of the patient with the view to reach a provisional diagnosis or possibilities 2-History should be obtained accurately because a good history leads to an accurate diagnosis of diseases.

SOURCE OF HISTORY
The history should be obtained directly from the patient But in case where the patient is a minor child , deaf or mute, demented, psychotic, unconscious or epileptic, history should be obtained from third person

CONTENTS OF HISTORY
An accurate history of the patient should be recorded under the following headings. 1. Brief introduction to patient. 2. Presenting or chief complaints. 3. History of present illness. 4. History of past illness. 5. Treatment history and drug history. 6. Family history. 7. Personal history. 8. Systemic enquiry.

TECHNIQUES OF HISTORY TAKING.

History taking is an art which comes with experience and an understanding of the human behaviour. It is a two way communication needing a empathetic attitude, common courtesy goes a long way towards good communication. History should be taken according to Patients condition and mode of admission. It is good to obtain history in patients language or consult a third person for translation if you are unaware of that language.

INTRODUCTION OF THE PATIENT

1. 2. 3. 4. 5. 6. 7.

NAME: it is important to record the full name because they may often be helpful to know the sex and religion of the patient. AGE: is important to note because some diseases are more common in different age groups. SEX: may often be evident from the name of the patient. It is important because certain diseases are common in females. RELIGION: certain diseases are more common in some religions as compared to others so it is important to know about religion of the patient. MARITAL STATUS: it helps to identify the social problems and responsibilities attached to married or unmarried state of the patient. ADDRESS: the full address of the patient must be recorded because this may give an idea of the diseases in that area and may be required to inform the relatives for any emergency. DATE AND MODE OF ADMISSION.

PRESENTING OR CHIEF COMPLAINT

The presenting complaint is a complaint which made the patient to seek medical advise. Lets suppose patient presents with an ear disease. You have to take history of presenting complaint under following headings. 1. Ear discharge: onset, duration, site, quantity, quality and colour and smell of discharge. 2. Ear ache: onset, duration, progression, site, severity and intensity. 3. Hearing deafness: duration, onset, site and severity. 4. Vertigo: onset, duration and severity. 5. Tinnitus: onset, duration, site and severity. 6. Ear irritation. 7. Fever and headache.

HISTORY OF PRESENT COMPLAINT

NOSE: NASAL OBSTRUCTION. NASAL DISHARGE. POST NASAL DRIP. IRRITATION OF NOSE AND EYES. FACIAL PAINS. EPISTAXIS. DISTURBANCES OF SMELL. OLFACTION THROAT: THROAT ACHE. SORE THROAT.

PAST HISTORY
Past history may be an important clue to the diagnosis of present illness. It should be taken a) Hypertension b) Myocardial infarction c) Any surgery/operation d) Diabetes e) Asthma f) Jaundice/hepatitis g) Pulmonary tuberculosis

DRUG HISTORY
Ask about the treatment and the drugs taken in the past because they may either give a clue to the chronic disorder or may be responsible for the present illness. Ask if the patient has had any allergy to certain drugs.

FAMILY HISTORY
It is particularly important if the patient is suspected to be suffering from infectious diseases or hereditary disorders. Health of all known relatives should be inquired and a family tree should be constructed showing those affected and non affected if hereditary disorder is suspected. Blood pressure Asthma Diabetes Jaundice/hepatitis Tuberculosis

SOCIO-ECONOMIC HISTORY
Occupation: firstly it gives an idea about the patients income thus helping in prescribing according to his pocket secondly the occupation may be directly related to the present disease thirdly repeated changes in jobs may indicate some physiological problems like inadequate personality. Diet and addictions: inquire about any food faddism or allergies, smoking and in case of smoking ,inquire about the mode and duration of smoking and the number of cigarettes smoked daily. Domestic and marital relationships: this gives an idea about the personality of the patient as a whole Home surroundings: sanitation and keeping of pets should be particularly noted. Travel abroad: may expose the patient to diseases which may be uncommon in his native country.