Write down the guidelines for History Taking Steps?

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HISTORY TAKING STEPS:

In it, First listen to the patient carefully, try to communicate in the language which the patient can understand,  then ask necessary questions to complete the history, and then write.

There are following steps while taking the history of a patient under following headings:

  1. Name, Age, Sex, Marital status, Occupation, Address.
  2. Presenting Complaints.
  3. History of present Illness.
  4. Systemic History.
  5. Past history
  6. Menstrual History
  7. Treatment History
  8. Family history
  9. Personal and Social History
  10. Occupational history
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1. General Information:
In general information, Age, sex, marital status and address of the patient involved.
  •  After knowing about age of the patient, we estimate about some common diseases regarding age factor like polio, chicken pox etc.
  • According to sex, some diseases are common in male and some in female, so we know about these diseases.
  • Complete postal Address is vital for future communication.
2.Presenting Complaints:
  • These are the symptoms which make the patient to come to the doctor. 
  • Record them in chronological order ( write the symptoms which developed first at the top followed by other complaints in sequence).
  • If a symptom has been occurring again and again, and is present this time as well, include this information in presenting complaints.
3.History Of Present Illness:
Describe the presenting complaints in detail one by one; in the sequence they developed . Relevant questions to be asked about various symptoms are learnt only with experience and increasing knowledge.
4.Systemic Inquiry:
The patient generally tends to tell only those symptoms which he thinks are important. Either he ignores other symptoms , considering them unimportant. So, we should ask about all the symptoms of each system. These includes following:
  • GENERAL: Appetite, Weight gain or weight loss, sleep, energy, fever.
  • Cardiovascular System: Breathlessness, Palpitation, chest pain, Edema.
  • Respiratory System: Cough, Sputum, Hemoptysis, breathlessness, wheezing.
  • Alimentary System: Nausea, Vomiting, Abdominal pain, Heartburn, Dysphagia, Diarrhea, Jaundice.
  • Urinary System: Dysuria, hematuria, frequency, Incontinence, oliguria, nocturia.
  • Nervous System: Weakness, tingling, headache, vomiting, giddiness.
  • Skin: Rash, Itch, Colored spots.
  • Locomotor System: Joint pain, Stiffness, Swelling.
5.Past History:
All the health related issues which occurred before longest presenting complaints. Inquire about the following:
  • Nature of delivery .
  • Congenital anomalies
  • Communicable Diseases in childhood
  • Vaccination
  • Any significant illness
  • History of admission to hospital, accident or operation
  • Residence or travel abroad.
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6. Treatment History:
In it, Ask about patient's ay left-over drugs, labels or prescriptions. Note down names of drugs, dosage and duration of therapy. Also ask about effect of these drugs on patient's illness.
  • Knowledge of drugs taken might give a clue to the nature of patient's past or existing disease.
  • Side effects of drugs are sometimes responsible for patient's symptoms.
  • Some patients are sensitive to drugs like sulfonamides, penicillin etc. and this information helps to avoid any catastrophes.
7. Family History:
Inquiry about health of parents and siblings , and ask questions about individual members.
  • Find out whether any one of them is suffering from a similar illness or a chronic illness like hypertension, diabetes mellitus, asthma, arthritis.
  • If any of them is dead, ask about possible cause of death.
8. Personal And Social history:
Seek the following information:
  • Patient's economic status.
  • Nature of family relations.
  • Any habit or addiction, like smoking, drug dependence.
  • Any special worries.
  • Dietary details.
Referances:
Bedside Techniques ( methods of clinical examination )
Editors: Muhammad Inayatullah and  Shabbir Ahmed Nasir.
https://www.shutterstock.com/image-photo/doctor-woman-sitting-male-patient-desk-347663228
About Author:
Tayyba Saleem ( PT ).
Doctor Of Physical Therapy.


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