IMPORTANT POINTS BEFORE HISTORY-TAKING
Introduce yourself Explain yourself Full attention Treat with respect Let patient talk Guide, not dictate No leading question No short-cuts Try not to write and talk to the patient at the same timePERSONAL DETAILS
NAME AGE SEX RESIDENCE RELIGOUS MARITAL STATUS OCCUPATION DATE OF ADDMISSION AND EXAMINATIONPRESENTING COMPLAINT
What are you complaining of? (record in patient’s own words) When more than one complain: (record in order of severity)HISTORY OF PRESENT ILLNESS
Full details of the complaint or complaints. Get right back to the beginning of the trouble. Each complain- fully analyzed e.g., pain Site Time and mode of onset ( sudden, gradual) Severity Nature (aching, burning, stabbing, constricting, throbbing) Progression Duration Aggravating/ relieving factors Radiation CauseSYSTEMIC INQUIRY of the involved or affected system
Example: Chief complaint related to gastrointestinal system(GI)- continue with the GIT inquiry.SYSTEMIC INQUIRY GASTRINTESTINAL SYSTEM
Weight Appetite Dysphagia Nausea Vomiting Heartburn Haematemesis FlatulenceJaundice Abdominal pain Fat intolerance Constipation Diarrhoea Melaena Rectal bleeding Stool
SYSTEMIC INQUIRY RESPIRATORY SYSTEM
Cough Sputum Hemoptysis Wheeze Dyspnoea Chest pain Smoking
SYSTEMIC INQUIRY UROGENITAL SYSTEM
Loin pain Dysuria Nocturia Frequency Haematuria Urinary stream Incontinence Urethral dischargeSYSTEMIC INQUIRY CARDIOVASCULAR SYSTEM
Angina (cardiac pain) Dyspnoea ( rest/ exercise) Palpitations Ankle swelling Claudication Varicose veinsSYSTEMIC INQUIRY
Obstetric & Gynecology LMP Vaginal discharge Vaginal bleeding PregnanciesNervous system Headache Fits Depression Facial/limb weakness
SYSTEMIC INQUIRY MUSCULOSKELETAL
Muscular pain Bone & Joint pain Swelling of joints Limitation of movements WeaknessPAST MEDICAL/SURGICAL HISTORY
Rheumatic Fever Tuberculosis/ Asthma Diabetes Jaundice Operations/ Accident Blood transfusion Mental illnessFAMILY HISTORY
Diabetes Hypertension Heart disease Malignancy Cause of death Father/Mother/Siblings/Spouse/Children/Close relatives