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    Outline For History Taking

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    Blanche
    The document outlines the sections to include when taking a patient's medical history: 1) General data such as name, age, occupation, address, hospital admissions. 2) Informant details and their reliability in providing information. 3) Chief complaint which is the symptom prompting the visit. 4) History of present illness including onset, treatments, symptoms details. 5) Past medical history of conditions, surgeries, allergies. 6) Family history of diseases. 7) Personal and social history including lifestyle, environment, and relationships. 8) Review of body systems to identify other relevant symptoms.

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    © All Rights Reserved
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    Outline For History Taking

    Uploaded by

    Blanche
    283 views2 pages
    The document outlines the sections to include when taking a patient's medical history: 1) General data such as name, age, occupation, address, hospital admissions. 2) Informant details and their reliability in providing information. 3) Chief complaint which is the symptom prompting the visit. 4) History of present illness including onset, treatments, symptoms details. 5) Past medical history of conditions, surgeries, allergies. 6) Family history of diseases. 7) Personal and social history including lifestyle, environment, and relationships. 8) Review of body systems to identify other relevant symptoms.

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    Clinical History Taking of Patients Guide

    Original Title

    Outline for History Taking

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    The document outlines the sections to include when taking a patient's medical history: 1) General data such as name, age, occupation, address, hospital admissions. 2) Informant details and their reliability in providing information. 3) Chief complaint which is the symptom prompting the visit. 4) History of present illness including onset, treatments, symptoms details. 5) Past medical history of conditions, surgeries, allergies. 6) Family history of diseases. 7) Personal and social history including lifestyle, environment, and relationships. 8) Review of body systems to identify other relevant symptoms.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    283 views2 pages

    Outline For History Taking

    Uploaded by

    Blanche
    The document outlines the sections to include when taking a patient's medical history: 1) General data such as name, age, occupation, address, hospital admissions. 2) Informant details and their reliability in providing information. 3) Chief complaint which is the symptom prompting the visit. 4) History of present illness including onset, treatments, symptoms details. 5) Past medical history of conditions, surgeries, allergies. 6) Family history of diseases. 7) Personal and social history including lifestyle, environment, and relationships. 8) Review of body systems to identify other relevant symptoms.

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    PHYSICAL DIAGNOSIS

    OUTLINE FOR HISTORY TAKING


    I. GENERAL DATA: Name, Age, Birthdate, Birthplace, Sex, Civil Status, Occupation,
    Nationality/Race, Religion, Present Address, number of times admitted in the hospital,
    name of the hospital patient is admitted in, time and date of admission.

    II. INFORMANT and % RELIABILITY:


    - may be the patient, relative, friend, any accompanying person, a
    letter of referral that can contribute largely on your patient’s medical
    history (to assess the value and possible biases of the information)

    - Reliability varies with knowledge, memory, trust, and motivation,


    among other factors, and is a judgement made at the end of the
    interview NOT at the beginning

    -
    III. CHIEF COMPLAINT/S: See Degowen
    > one or more symptoms or other concerns for which the patient is seeking care
    or advise
    > Usually the answer to the question, “What symptom brought you to the
    hospital?”
    > Should be limited to a succinct word, phrase, or sentence, preferably as a
    direct quote from the patient

    IV. HISTORY OF PRESENT ILLNESS: See Degowen


    > Determine as accurately as possible the date and manner of onset.
    - develop the illness chronologically, analyze each symptom as it arises
    > The patient’s previous treatment. Mention generic and brand names of the drugs
    used. Include dosage, preparation, duration of use.

    > Describe symptoms in terms of:


    1) Provocative/Palliative (Factors that have aggravated or relieved them)
    2) Quality
    3) Radiation/Location (Where is it?)
    4) Severity/Quantity (How bad is it?)
    5) Timing (i.e., onset, duration, and frequency)
    6) Setting in which they occur ( environmental factors, personal activities,
    emotional reactions or other circumstances that may have contributed to the
    illness)
    7) Associated manifestations

    > NOTE pertinent negatives ( the absence of certain symptoms that will aid in
    differential diagnosis)
    V. Past Medical History:
    > previous hx of infectious disease – childhood and adult (list dates and
    complications)
    > immunization
    > hx of operations, injuries, blood transfusions and operative diagnoses (list dates)
    > previous hospitalization (list dates, diagnoses and names of hospital)
    > Hx of previous and present disease NOT related to the present illness
    > Allergies

    VI. FAMILY HISTORY: See DeGowin and Bates


    > includes chronic and degenerative disease, infections, neuro-psychiatric
    disorders, and other heredo-familial diseases
    > Parents, siblings, spouse or children - Age and health or age at death and cause

    VII. PERSONAL & SOCIAL-ENVIRONMENTAL HX: see Bates and Degowen


    - provision of information about the patient’s environment and what manner of
    person the
    patient is
    - Personal:
    > lifestyle issues that create risk or promote health, and health
    maintenance issues ( e.g. smoking, food preference)
    > Birthplace & Place of residence
    > Marital History
    > Gender preference
    > Habits
    > Religious affiliation and beliefs

    - Social and economic status – standard of living, occupation, educational


    attainment

    - Environmental - description of place of residence and its


    surrounding area;
    - includes number of members in the household, drinking water
    supply, toilet facilities, source of light (e.g. candles, electricity, gas)

    VIII. REVIEW OF SYSTEMS: see DeGowin and Bates


    > review of the history; inquiring for salient symptoms associated with each
    system or anatomic region
    > primarily, this is a search for symptoms that may have escaped during the
    taking of the history of the present illness.
    > place symptoms related to the present illness in the History of Present Illness;
    anything unrelated to the HPI must be place in the Review of systems.

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