Chapter 2
History taking
To obtain information about the patient, Physician asks specific questions either to the patient or from the people who know the person and can provide suitable information. This is labeled as Medical Case History abbreviated as hx or Hx.
The information obtained this way, along with physical examination, enables the health professionals to form a diagnosis and treatment plan. If a diagnosis cannot be made, a provisional diagnosis may be formulated, and differential diagnoses may be added. The treatment plan may then include further investigations to clarify the diagnosis.
Method
Clinicians need to obtain the following information about the patient:
• Identification and demographics like: o Name o Age o Address o Occupation …show more content…
• Chief complaint: The major health problem or concern or problem that forced patient to come to the hospital and its time course.
• History of present illness: Details about the complaints, specified in the chief complaints often called 'History of presenting complaint.' While enumerating upon the chief complaints physician should enquire chronologically about each and every complaint listed, and obtain details about their: o Onset: whether onset is gradual or rapid. o Pattern: whether it gets bad to worse or better. What does patient do when symptom begin. o Time course: when symptoms last felt, if condition is chronic. o Severity: of symptoms on scale of …show more content…
• Past medical history: It includes detailed history of major illnesses, any previous surgery, sometimes distinguished as ‘Past Surgical History’, any current ongoing illness, e.g. Diabetes, Hypertension, Tuberculosis, etc. Any treatment prescribed for such conditions.
Drugs which remain relevant are corticosteroids, oral contraceptives, antihypertensives, chemotherapy and radiotherapy etc.
• Review of systems: Systematic questioning about different organ systems.
• Family history: Especially the conditions; which are relevant to the patient's chief complaint.
• Childhood history: is of paramount importance in paediatrics.
• Social history: Including living arrangements, occupation, marital status, number of children, drug use like tobacco, alcohol or other recreational drug use, recent foreign travel and exposure to environmental pathogens through recreational activities or pets.
• Treatment history: Enquire about regular and acute medications including those prescribed by doctors, obtained over-the-counter or alternative medicine.
• Allergies: To medications, food and other environmental factors.
• Sexual history: It includes obstetric/gynecological history.
• Conclusion
Review of
History taking
To obtain information about the patient, Physician asks specific questions either to the patient or from the people who know the person and can provide suitable information. This is labeled as Medical Case History abbreviated as hx or Hx.
The information obtained this way, along with physical examination, enables the health professionals to form a diagnosis and treatment plan. If a diagnosis cannot be made, a provisional diagnosis may be formulated, and differential diagnoses may be added. The treatment plan may then include further investigations to clarify the diagnosis.
Method
Clinicians need to obtain the following information about the patient:
• Identification and demographics like: o Name o Age o Address o Occupation …show more content…
• Chief complaint: The major health problem or concern or problem that forced patient to come to the hospital and its time course.
• History of present illness: Details about the complaints, specified in the chief complaints often called 'History of presenting complaint.' While enumerating upon the chief complaints physician should enquire chronologically about each and every complaint listed, and obtain details about their: o Onset: whether onset is gradual or rapid. o Pattern: whether it gets bad to worse or better. What does patient do when symptom begin. o Time course: when symptoms last felt, if condition is chronic. o Severity: of symptoms on scale of …show more content…
• Past medical history: It includes detailed history of major illnesses, any previous surgery, sometimes distinguished as ‘Past Surgical History’, any current ongoing illness, e.g. Diabetes, Hypertension, Tuberculosis, etc. Any treatment prescribed for such conditions.
Drugs which remain relevant are corticosteroids, oral contraceptives, antihypertensives, chemotherapy and radiotherapy etc.
• Review of systems: Systematic questioning about different organ systems.
• Family history: Especially the conditions; which are relevant to the patient's chief complaint.
• Childhood history: is of paramount importance in paediatrics.
• Social history: Including living arrangements, occupation, marital status, number of children, drug use like tobacco, alcohol or other recreational drug use, recent foreign travel and exposure to environmental pathogens through recreational activities or pets.
• Treatment history: Enquire about regular and acute medications including those prescribed by doctors, obtained over-the-counter or alternative medicine.
• Allergies: To medications, food and other environmental factors.
• Sexual history: It includes obstetric/gynecological history.
• Conclusion
Review of