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History taking
Muhamad Zaidan
Dec 17, 2016 • 18 likes • 2,155 views

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Health & Medicine

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1. History taking By Dr/ Muhamad Fathy Zydan (MD)
2. • Personal H, including menstrual H in females • Presenting complaint • History of the present illness • Past H of illness • Treatment
H • Family H
3. Personal History • Name • Age • Sex • Residence • Occupation • Marital status • Menstrual H • Special habits
4. Personal History • A male patient called Muhamad Ali, 68 years old, born and raises in El-Fayoum Egypt, Driver, Married 41 years
ago and has 4 ( children's , o!spring's ) the (last one , youngest) is 22 years old, he smokes 50 cigarettes per day for 48 years.
5. Age related diseases
6. Age related I.O • D1= (Atresia- Malrotation- HSD- Meconium ileus- congenital web or Bands – hernias- imperforate anus) • 5-6 weeks
= CHPS • 6-12 months = Intuss • Adult (hernias- masses – adhesions- inflamatory process …) • Old age (Malignancy- adhesive-
inflammatory process -volvulus – ..)
7. Sex related D.
8. Residence and Race related D
9. Occupation • Sun exposure • Drivers • Sport • Chemicals • Long standing • Weightli"ing • Work related Bursa
10. Occupation
11. Marital state • Fertility and No. of children's • Include the menstrual and obstetrical H at this point • Breast feeding • Methods of
contraception • Sexual transmitted diseases
12. Menstrual and obstetric history • Age of menarche • Duration of the menses, Regular or not ,and kind of irregularity and for how
long • No. of pregnancies • First full term pregnancy • Date of the last menst. Cycle • Age of menopause • Bleeding a"er menopause
14. Special habits • Smoking related cancers and other diseases • Alcohol related diseases • Injections related diseases
15. Complaint
16. Complaint • What are you complaining of ? • What is the matter ? • One complain better • The most disturbing one if many • By the
patient’s own words • No medical terms ( yellow discoloration of the sclera not jaundice )
17. Complaint • PAIN • lump • Bleeding • Disfigurement • GIT (N ,V, CONST., D., DISTENTION, …..) • OTHER SYS . ??
18. PRESENT HISTORY • A-Analysis of the complaint • B-Symptoms of the related system • C-Symptoms of the other systems
19. Present history A-Analysis of the complaint 1-OCD (Onset- Course –Duration ) 2-Detailed history about the complaint
20. 1-OCD Ask the patient about the last time he was quite well and from that you can record the duration of his illness
21. OCD mode of ONSET • Instantaneous or sudden , when the symptoms develops and reaches its maximum in just few seconds or
minutes • Acute , symptoms develops over hours or days • Gradual, takes several weeks to develops • Accidentally discovered , by the
patient or his doctor during routine check up
22. Onset
23. OCD the course • Progressive • Regressive • Stationery • Remittent (not returning to the normal state) • Intermittent ( with
intervening periods of feeling normal)
24. Analysis of the complaint 2-Detailed history about the complaint EXAMPLE 1 COMPLAINT = PAIN 1-OCD 2-Site (localized or
di!used) 3-Radiation or if referred to any site 4-Character 5-Sevirity ( how it a!ects the patient life ) 6-Relation to trauma 7-What
aggravates it 8-What relives it 9-Associated symptoms
25. Pain as a complaint Breast pain (Mastalgia) • OCD (PAIN started 2 days ago with sudden onset and rapidly progressive course ) •
Started at the nipple a"er an abrasion by her nursing baby teeth • Hours later referred to upper lateral sector of the breast and the
homolateral axilla • The pain started mild and sharp , day later become sever and throbbing • At first it decreased by elevation and
mild analgesic , later no analgesics a!ecting its severity • Increased by breast feeding • Associated first by abrasion on the nipple , later
by redness and swilling at the upper lateral segment of the breast
26. Pain as a complaint UNILATERAL LOWER LIMB PAIN • OCD (PAIN started 8 hours ago with sudden onset and rapidly progressive
course ) • Started at the mid thigh level ( le" side) and extended distally to the tips of toes • The pain very sharp and sever • Aggravated
by motion and slightly decreased by dependency • Not a!ected by analgesic • Associated by sense of coldness in the same limb and
change in color • Associated by numbness and motor weakness
27. Detailed history about the complaint EXAMPLE 2 COMPLAINT = lump 1-OCD 2-Site 3-Relation to ( pain – trauma – constitutional
manifestation) 4-Possible cause 5-Special character 6-E!ect of swelling on body function (movement, respiration swallowing …) 7-
Dose it ever disappears 8-Other swelling on the body
28. Swelling as a complaint Breast mass • OCD (Swelling accidentally discovered on the le" breast 2 weeks ago with slight
progression on its size) • Painless • No relation to trauma • No other swelling on the other breast , homolateral or contralateral axilla
29. Swelling as a complaint Neck mass • OCD (Swelling appears in front of the neck 12 years ago with slight progressive course during
the 1st 11 years then rapidly increase in size during the last 6 months) • Painless • No relation to trauma • No other swelling on the
neck. • No special character
30. Present history B-Symptomes of the related system Example 1 ( complaint abdominal pain ) 1. Taste 2. Dysphagia 3.
Hematemesis, vomiting , heart burn, eructation 4. Melena, fresh bleeding per rectum, defecation, distention 5. Fatty dyspepsia 6. Liver
cell failure manifestation
31. Analyze any positive symptom • Example 1 (Nausea) 1. Is it related to food 2. Whether accompanied by vomiting 3. Is the patient
taking any medicine • Example 2 (Vomiting) 1. Frequency 2. Preceded by nausea or not 3. Relation to meals 4. Relation to pain 5.
Quantity and nature of the vomitus and its color 6. Associated pain ,tinnitus or diarrhea
32. • Example 3 (constipation) 1. What is the usual patient habit? 2. Duration 3. Partial or complete 4. Any alternating diarrhea 5.
Constipating drugs (e.g. codeine) 6. In infants ask about • Passage of meconium • Uses of enemas and laxatives • Any alternating
periods of normal defecation • Psychic trauma • Abuse
33. • Example 4 (Bleeding per rectum ) 1. OCD 2. Frequency 3. Color 4. Amount 5. Relation to defecation 6. Associated pain and its
relation to defication 7. The passage of mucus 8. Bleeding from other orifices 9. Bluish spots on the skin 10. Manifestation of chronic
blood loss
34. Present history C-Symptomes of the other system (review of body systems ) Again Analyze any positive symptom E.g.(cough) 1.
Frequency 2. Dry or productive 3. Painful or not 4. Relation to posture 5. What worsen it and what relive
35. Past history • Any previous illness should be inquired. • They should be recorded in chronological sequence with the date of their
occurrence and duration. • Similar attacks. • Medications and surgical operation. • Ask about common diseases …DM , HTN , Heart
diseases • History of previous admission to hospitals and mention the cause and history of blood transfusion if present.
36. Treatment history • Details of drugs taken. 1. Type 2. Indication 3. Duse and duration 4. Possible adverse reaction and
hypersensitivity. • Surgery 1. Its time 2. Type of operation and its indication 3. Surgeon and hospital 4. Type of anaesthesia 5. Duration
of hospital stay 6. Possible complication and outcome • Radiotherapy • psychotherapy
37. Family history • Enquire about the health and age of the patients parents, grandparents, brothers, sisters, and children • If not
alive enquire about the cause of death • If the patient is a child you need the following information 1. The mothers pregnancy 2. Did
she take any drugs during pregnancy 3. Birth weight 4. Any di!iculties during delivery 5. Mental and physical development in early life
• Enquire about important diseases which have known to have occurred in the patients immediate relatives
38. Thank you

Editor's Notes
1. 1- Sacro-cocc.T 2- st mast tumor Cystic H 3- Ranula 4- lymphoma 5-Str B.H 6-Branch cyst
2. Thyroid diseases F hernia Breast canc
3. Madura foot stomach canc Burck lymphoma
4. Student Bursa ,, hosemade Bursa ,, pilnidal disease ,,VV,, Inclosion Dermoid,,SCC

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