HISTORY TAKING

Greetings

, mera name ------------ ha ,mein aik medical ka talib e ilm hn, mjhy apsa apki bimari ka bara mein chnd
sawalt krna ha or apka muaina krna ha , js sa apki bimari ki tashkhees mein mdad mila gi , kia ap iski
ijazat deta hn, umeed ha ap tauwun krein ga

(introduction , must be completed in one minute)

Name

Father name

Gender(ischemic heart disease more common in male),same carcinoma of rectum,

Age(if 60 year old male with bleeding per rectum, then some carcinoma,if child then other problems,male with urine retention ,obvious
prostate)

Address

Occupation(carcinoma related to industry)

PRESENTING COMPLAINT

Admitted through opd/emergency.

What brought you to hospital?

Will not have any medical terminology.

e.g patient says I have ,pain in specific region,vomiting, fever, ( if ,presenting complaint is more than one ,then it must be
in sequence from high to low days)

it must be objective (mtlb tamam logon ka liye us complaint ka mtlb aik jesa ho )

it must be in patient language ( pain in upper abdomen,lower abdomen ,generalized pain ,having some swelling,vomiting , bleeding,
discharge , deformity, fatigue, diarrhea, constipation)

MOVE on to history of presenting complaint

If patient has pain

Then ask

Site (kia ab jagah bta skta hn Jahan drd mehsoos ho rhi apko)

Onset (pain kb shuru hui or , kahan shuru hui, jb drd shuru hui , tb ap kia kr raha tha , drd kesa shuru hui ahista sa, or achank sa )

Character( chubhti ha , jalann ka sath ha, mror ata hn , thori koi marta ha , in sequence aching/ sharp, burning, colicky, throbbing, ) is it
constant / variable.)
Radiation ( kia drd ki jagah mein koi tabdeeli to anhi ati , )

Timing ( ye drd apko kbsa ho raha ha , 6 ghnata , 1 dinn jo bhi , kia aisa drd apko pihla bhi kbh hua tha , agr hua tha to donon mein koi khas
frq tha )

Exacerbating factors/ relieving ( kia kam krna sa drd mein shidat ati ha , jb ap lait jata hn to / chlna lgta hn / rest krta hn / mkoi
dawai leta ha / pakahana kharij krta hn to kia drd ki shidat mein kami ati ha ya or bhi brh jati ha, sans lena sa drd ki shidat mein koi tbdeeli

Khana khanay sa aksar , pancreatitis , gallbladder , ischemia of intestine ki drd brh jati ha)

Shidat kesi ha (kia is drd ki waja sa apka mamoolat e zindagi mutasir ho rha hn , kia is sa apki nind mutasir hoti ha?)

ASSOCIATING FACTORS

Where else did you feel it ,

general Gastrointestinal vomiting faccssit

diarhhea Medicati Din Rng Musalsal

on / mein kesa ati ha or
fasting kitni dfa hota theek
ati ha bhi ho
How many Recurre jati
stools per day ncy
Miqdar Kisi Am tr pr
Amount of Any kitni khas kis waqt
stool medicin hoti ha wja sa ati ha
e ulti ati
ha
Watery/custard
like Us mein Frq kis Kia sath
kia hta chez sa pait
Contents,muco khoon prta ha mein
us,fat blood to nhi drd hta
ha ,
Relation of food diarhea
with motion

Sweating Jalan hoti ha Fever

fever Khana nigalna mein dushwari Onset and duration

Sans lena mein dushwari Did you check it with

thermometer ,vip (clarification)

Khara hna pr , chkr to ni Timing( continuous ,

ata intermittent , at which time of
 day rises,

Relieving factors/ associating

factors

Did you check it with

thermometer ,vip

Swelling( site of swelling , size , achank bri hui or kuch dion mein waqfa waqfa sa ,associated factors, is ki
wja sa kisi or jga koi pressure/ pain to nhi feel ho rhi , kia apna khud usko observe kia or kisi or na btaya

Kitni arsa ya swelling ha apko

Swelling ki present complaint mein swelling or lump hi likhn ga,

Onset ( sudden , acute , gradual , insidious, )

Character( single ha ya multiple) , appear ya dis appear , hernia cough brh gai ,letna sa sai ho gai

PAST MEDICAL HISTORY (Kia pihla kabhi ap hospital mein dakhil hua, koi abdominal operation hua ho
pihla, pihla kbhi indigestion or pain ki shaqait hui ho, DM , HT , TB , wagera, female of menstrual
bleeding,asthma, epilepsy(mrgi), yrqan (jaundice)

Drug history

Allergy history

Social history ( smoking , alcohol, occupation, heavy lifting , hernias, bimari ki waja sa mamoolate zindagi
mein tabdeeli, ati ho ,

Family history ( diasease / illness run in family, family mein koi malignancy ki history, )

Systemic (cvs resp nervous genitourinary)

General Cardiology Gastroenterology – mouth

ulcers, indigestion, dysphagia,
jaundice, nausea, vomiting,
haematemesis, diarrhoea (How
often? describe), constipation,
abdominal pain, masses, rectal
bleeding (Is it mixed in or on
paper?), change in bowel habit

Apetite Pain in chest, sans lena mein Neurology – 3 Fs (fits, faints,

 masla,chkr to ni ata funny turns), pins and needles,
numbness, difficulty walking,
headaches, weakness,
unsteadiness, vertigo

Weight loss respiratory

fatigue Blgum mein khoon ana, dysuria, frequency, nocturia,

khansi,sai trah sa sans na ana
haematuria, incontinence,
hesitancy, poor stream,
offensive smell, terminal
dribbling, menstrual cycle,
sexual function

Finish with: Is there anything else that you would like to tell me that I haven’t asked you about already?
Do you have any questions before we finish? Is there anything that you are worried about?

Apka tawun ka bht shkuria , agr apka koi sawal ha to poochiye.