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    History Taking Handbook

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    youservezeropurpose113
    The patient's history taking record provides information about their chief complaint, history of present illness, review of multiple body systems, past medical history, past surgical history, family history, personal and social history, occupational history, drug history, and allergies. The record is used to document the essential details about a patient's condition and relevant background to inform their diagnosis and treatment.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    History Taking Handbook

    Uploaded by

    youservezeropurpose113
    40 views2 pages
    The patient's history taking record provides information about their chief complaint, history of present illness, review of multiple body systems, past medical history, past surgical history, family history, personal and social history, occupational history, drug history, and allergies. The record is used to document the essential details about a patient's condition and relevant background to inform their diagnosis and treatment.

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    The patient's history taking record provides information about their chief complaint, history of present illness, review of multiple body systems, past medical history, past surgical history, family history, personal and social history, occupational history, drug history, and allergies. The record is used to document the essential details about a patient's condition and relevant background to inform their diagnosis and treatment.

    Copyright:

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

    History Taking Handbook

    Uploaded by

    youservezeropurpose113
    The patient's history taking record provides information about their chief complaint, history of present illness, review of multiple body systems, past medical history, past surgical history, family history, personal and social history, occupational history, drug history, and allergies. The record is used to document the essential details about a patient's condition and relevant background to inform their diagnosis and treatment.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    History Taking Record

    Name Age Gender Occupation Marital Status Residency Religion


    Date of Admission Date of taking history Mode of referral Mode of
    arrival
    Chief Complaint and duration: Why you’ve come to hospital? Own words.
    History of Present illness:
    When were you last well? What was the first thing you noticed when you became ill?
    Obtain full descriptions of any other symptoms that the patient has.
    Regarding Pain ask about (Site, Onset, Character, Radiation, Duration, Periodicity,
    Severity, Aggravating factors, Relieving factors, Associated symptoms).
    Review of Systems:
    1. General: Appetite, Weight (loss or gain), Fever, Sweating, Rigors, Night sleep
    (difficulty or disturbance), Mood, Daily activity.
    2. Cardiovascular system: Chest pain on exertion, Dyspnea, Orthopnea
    (shortness of breath when lying down or need to sit up to breathe), Paroxysmal
    Nocturnal Dyspnea (waking up at night with shortness of breath), Palpitation
    (irregular heartbeats or sensation that your heart is racing or skipping beats),
    Oedema (swollen ankles), Pain in the calves on walking.
    3. Respiratory system: Cough, SOB (Exercise tolerance), Chest pain due to
    inspiration or coughing, Wheezes, Sputum (Color/ amount/ consistency/ odor),
    Hemoptysis.
    Breasts: Lumps, Change in shape, Nipple discharge.
    4. Gastrointestinal: Dysphagia (difficulty swallowing), Dyspepsia (Indigestion/
    heartburn), Excessive belching (eructation), Nausea (feeling like you are going to
    throw up), Vomiting/ vomitus details, Abdominal pain, Change in bowel habit,
    (diarrhea, constipation or alternating), Blood loss (hematemesis, melena or rectal
    bleeding), Incontinence.

    5. Genitourinary: Dysuria (burning when you urinate), Frequency (urinating


    often), Hematuria, Urine volume& colour, Urgency (need to urinate suddenly),
    Nocturia, Hesitancy (slow to start urinating), Drippling, Incontinence (loss of
    control of urinating), Genital rashes, Lumps, Vaginal pain/discharge, Hot flushes
    (females), Urethral discharge (males).

    6. Nervous system: Headache, Fits, Coma, Faints, Dizziness, Limb weakness


    (paralysis), Numbness (parasthesia) or Anesthesia, Unsteadiness, Tremors (shaking
    that you can’t stop), Concentration, Memory, Vision (blurred, double), Hearing
    (decreased, tinnitus), Difficulty with speech.
    7. Musculoskeletal: Joint pain (arthralgia), Stiffness, Joint Swelling, Difficulty
    moving or walking, Dry mouth, Sore eyes, Back or neck pain, Myalgia, Frequent
    fractures.
    8. Menstrual and Obstetric history: Menstrual cycle (menarche, regularity,
    amount), Menopause (age, postmenopausal bleeding), Pregnancy (number, type of
    labor and outcome), Abortions and stillbirths, Method of contraception if any.

    9. Endocrine: Heat or cold intolerance (feeling unusually hot or cold), Fatigue,


    Neck swelling, Polydipsia, polyuria, Fine tremor, loss of sexual drive (libido).
    10. Hematological: Bruise easily, Bleed excessively, Bleeding spots, Lumps in
    (axilla, neck, groins), Frequent or unusual infections.

    11. Mucocutaneous symptoms: Hair loss, Skin rash, Itching, Skin ulcers,
    Pigmentation changes, Hair or nail changes, Lumps, Mouth ulcers, Epistaxis.

    Past Medical history:


    Past history of similar present condition, Chronic conditions and significant illnesses
    according to the case, e.g. (diabetes, hypertension, angina and myocardial infarction,
    jaundice, tuberculosis, rheumatic fever, epilepsy, asthma, stroke), and
    Hospitalization.
    Past Surgical history:
    Previous operations (under general or local anesthesia), other procedures (e.g.
    angioplasty, endoscopy), Post operative complications, Blood transfusion.
    Family history: History of similar illness in the family, History of HT, DM, IHD, TB.
    Ask about first degree relatives (their age, their state of physical& mental health or
    cause of death).
    Personal& Social history: Smoking – pack years, Alcohol (amount& type), Home
    situation, Mobility& Help at home, Diet& Water supply, Recent overseas travel,
    Hobbies, Animals in the house, Sexual history.

    Occupational History: What did they do? How long did they do it for? Anything
    medically relevant in what they did (Mining, Painting, Farmer, Cheese worker, Pigeon
    fancier...)
    Drug History: Get a list of prescribed medications, Over the counter medications,
    Alternative therapies like herbs.
    Allergies: List drug allergies and type of reaction, List other possibly relevant allergies
    (e.g. latex, food), Problems with anaesthetics.

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