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    The document outlines the main parts of a patient's medical history that should be collected, including demographic data, chief complaint, history of present illness, review of major body systems, and past medical, surgical, family, social, and drug histories. It describes the key information to gather under each section, such as the patient's name, age, symptoms, duration of illness, past hospitalizations, surgeries, medical conditions, social habits, and medications including allergies and current prescriptions. A thorough history taking allows the healthcare provider to understand the full clinical picture of the patient.

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    The document outlines the main parts of a patient's medical history that should be collected, including demographic data, chief complaint, history of present illness, review of major body systems, and past medical, surgical, family, social, and drug histories. It describes the key information to gather under each section, such as the patient's name, age, symptoms, duration of illness, past hospitalizations, surgeries, medical conditions, social habits, and medications including allergies and current prescriptions. A thorough history taking allows the healthcare provider to understand the full clinical picture of the patient.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    11 views14 pages

    11 PDF

    Uploaded by

    Ameer Ali
    The document outlines the main parts of a patient's medical history that should be collected, including demographic data, chief complaint, history of present illness, review of major body systems, and past medical, surgical, family, social, and drug histories. It describes the key information to gather under each section, such as the patient's name, age, symptoms, duration of illness, past hospitalizations, surgeries, medical conditions, social habits, and medications including allergies and current prescriptions. A thorough history taking allows the healthcare provider to understand the full clinical picture of the patient.

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    © All Rights Reserved
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    of 14

    HISTORY TAKING

    MAIN PARTS OF HISTORY


    Demographic Data (DD)

    Chief Complaint (CC)

    History of Present Illness (HOPI)

    Systemic Review (SR)

    Past History (PH)


    DEMOGRAPHIC DATA

    u Name
    u Age
    u Gender
    u Race
    u Marital status
    u Residence
    u Occupation
    u Religion
    CHIEF COMPLAINT

    1- One or Two symptoms that


    brought the patient to the
    hospital

    2- the duration
    HISTORY OF
    PRESENT ILLNESS
    uDetailed story of the condition
    in the words of the patient.

    uItinvolve the system that the


    chief complaint is encountered
    within.
    SYSTEMIC
    REVIEW
    Gastrointestinal tract (GIT)
    Cardiovascular system (CVS)
    Respiratory system (RS)
    Urogenital system
    Neurological system
    Musculoskeletal system
    .
    PAST HISTORY
    uMedical
    uSurgical
    uFamily
    uSocial
    uDrug
    PASTMEDICAL Hx
    u Hospitalization
    u The following diseases should always be asked
    about:
    u Ischemic heart disease (IHD)
    u Cerebrovascular accident (CVA)
    u Diabetes mellitus (DM)
    u Hypertension (HT)
    u Bleeding tendency
    PAST-SURGICAL Hx
    1. Any Hx of trauma
    2. Hospitalization
    3. Surgical procedures
    • Type of surgery
    • Indication
    • Type of anesthesia
    • Complications
    • Blood transfusion
    FAMILY Hx
    •No of children (suns and daughters)
    •Father and mother
    •Any family disease
    •Any sudden death in first and
    second degree relatives
    •Any cancer in the family
    SOCIAL Hx
    u Social habits (alcoholism and
    smoking)
    u Job properties
    u Finantial issues
    u Home conditioning
    u Geographical residence
    (sanitation, water supply,
    domestic animals, …etc)
    DRUG Hx
    Drug allergies (eg:penicillin )

    Dugs used to treat medical


    diseases
    Certain groups of drugs should
    always asked about directly:
    u Nonsteroidalanti-inflammatory drugs (NSAIDs)
    u Steroids
    u Antiplatelets (Aspirin)
    u Anticoagulants (heparin and warfarrin)
    u Oral hypoglycemic drugs (OHD)
    u Oral contraceptive drugs (OCP)
    Thanks

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