Though I use this pattern in Medicine for taking history from a patient. There is further room for improvement if anyone improves it, I will be really thankful.
History Outline
Personal Profile: Name ______
Age ______
Gender _____
Occupation ________
Residence __________
Marital Status ________
Education ________
Blood Group ___________
Mode of Admission ___________
Date of Admission ____________
Presenting Complaints: All complaints in chronological order must be noted with their duration.
For example; If patient complains about chest pain from 1 year, fever from 6 days and cough from 10 days then your presenting complaints will be like this.
My patient has chest pain for 1 year.
Cough for 10 days.
Fever for 6 days.
Note: I have arranged these complaints in chronological order. Here one thing that you should keep in mind is NOTE THE PRESENTING COMPLAINTS IN PATIENT'S OWN WORDING.
History Of Presenting Complaints: This is the part of history that matters most in making your diagnosis. If you have noted the complaints clearly then keep in mind you have at-least 4 to 5 common diseases in back of your mind that you are specially gonna ask in this session. Pick an individual complaint inquire about it and describe its characters and try to have a little idea about its origin.
For Example: If I will pick up the same presenting complaints then i will inquire about pain somewhat like this.
Pain:
What is the site? ... Multiple problem with a single site of pain like epigastric pain in Angina and gastric ulcer ... !!!
Duration? ... !!!
Is it continuous or intermittent? ... Like unstable and stable angina ... !!!
Is it sharp in nature or dull? ... Like pain in gastric ulcer and angina ... !!!
Does that pain radiate towards any site like back or to the jaw? ... like gastric ulcer, cholecystitis and angina or muscular pains of chest ... !!!
Is that pain relieved by any factor or is it aggravated in certain other conditions? ... like chest pain associated with heart get worse during exertion, respiratory pain gets worse during breathing and coughing, gastric ulcer pain gets worse during eating, duodenal ulcer pain gets good after eating ... !!!
Is that pain associated with any other condition? ... like cardiac pain is associated with shortness of breath ... !!!
Does pain follow any specific pattern? ... pain pattern of gastric and duodenal ulcer.
After inquiring about all complaints, explain to examiner your important positive answers plus important negative ones too. Now, if there is any symptom of the complication of a previously diagnosed disease like neuropathy in diabetes then you can say it like "My patient is a known case of DM from this long and then repeat the above story"
NOTE : Try to direct your questions towards a specific cause and try to eliminate the least possible.
Systemic Review : Most of the students think that it is an unimportant part of history but believe me it can add a valuable information in your diagnosis. Like if a 32 years old female patient presents with vague abdominal pain and you take a detailed history of GIT but skip GYNAE then, my friend, you have made a blunder. It can be Pelvic Inflammatory Disease.
Start questioning systemically. Some common questions you may ask in different systems like;
CNS: Headache, Dizziness, Diplopia, Seizures, Epilepsy, Sleep Disturbance, Visual Disturbance.
CVS: Palpitations, Dyspnea, Orthopnea, Paroxysmal Nocturnal Dyspnea, Cyanosis, Excessive Sweating, Radiating Chest Pain.
Respiratory: Cough, Dyspnea, Expectoration, Color of Expectorant, Hemoptysis, Shortness of Breath, Wheezing.
GIT: Weight loss, Appetite, Nausea, Vomiting, Hematemesis, Diarrhea, Constipation, PR Bleed, Abdominal Pain, Malena.
Urology: Urine Color, Hematurea and irritative + obstructive symptoms.
Genital system: From males, inquire about their sexual habits and from females, take a short review of gynae/obs history.
Musculoskeletal System: Joint pains, swellings, movement limitations, muscular spasm, tingling, numbness, abnormal movements.
Psychiatry: You may inquire about 5 major aspects i.e anxiety, depressive illnesses, mania, personality disorders, functional disorders.
Past History;
Medical: Ask the patient that has he been ill ever or has he been admitted in the hospital ever. Don't act like a goof. Think smart and keep in mind all major diseases like DM, Hypertension, Asthma, CVS problems or about a disease that can be a risk factor of his present illness.
Surgical: Ask about any surgical procedure done in her life.
Family History: Now family history is very much related to certain medical conditions like sudden death of young adults may be an indication to dilated cardiomyopathies. DM has a strong genetic predisposition. Asthma may affect other family members too. Breast carcinoma often runs in family patterns. In Asia, ask the patient about Hepatitis B,C and AIDS. You may ask about certain other genetically transmitted disorders like hemophilia if the person is with bleeding disorders.
Allergic History: Ask for potential allergens.
Drug History: Inquire about medication patient has been using because it may actively interact with the drugs of your management plan.
Addiction: Ask for addiction like alcohol, smoking, paan, naswar or other habit making things.
Blood Transfusion History: Ask the patient that has he ever been transfused with blood or not? You can have ideas about any transmitted disease, trauma, surgery, anemia.
Homeopathic Medicine: In Asia, people use herbal medications a lot. You may inquire about that too. That may give idea about previous management and chronic nature of disease.
Socio-Economic Status: This can be asked in dignified way without making the patient feeling embarrassment. Like; Ask the patient how much family members he has, how much earning hands he has, how much rooms he has in his home? ... Last question sounds stupid but trust me it can be a clue for a disease like scabies. You may designate this portion as satisfactory or unsatisfactory socio-economic status.
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