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    History Taking and Vital Signs: Hawler Medical University - College of Dentistry

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    History Taking and Vital Signs: Hawler Medical University - College of Dentistry

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    History Taking and Vital Signs: Hawler Medical University - College of Dentistry

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    pj2g2phmyk

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    Hawler Medical University - College Of Dentistry

    Made by: Tawar Rebwar Nuri


    Supervised by: Dr. Dlshad Chomani
    Report of: BEC

    Date: December 1st, 2024

    History Taking
    And
    Vital Signs

    1
    History taking:

    Taking history from a patient is a skill necessary for examinations


    and afterwards as a practicing doctor, no matter which area you
    specialize in. It tests your communication skills and your
    knowledge about what to ask. The basis of a true history is good
    communication between doctor and patient.
    Taking history from a patient is important because It can help in
    making well-informed decisions about care. Going into past
    medical conditions, family history, lifestyle factors and existing
    symptoms enables providers to identify risk factors, diagnose
    conditions accurately and develop personalized treatment.

    There are some steps to take history from a patient:


    Step 1: Introduce yourself
    Identify your patient and gain consent to speak with them. You
    should take notes as you proceed, ask the patient’s permission to
    do so.

    Step 2: Presenting Complaint (PC)


    This is what the patient tells you is wrong.
    For example: Chest pain.

    Step 3: History of Presenting Complaint (HPC)


    Gain as much information you can about the specific complaint.

    2
    Step 4: Past Medical History (PMH)
    Gather information about a patient’s other medical problems
    (if any).

    Step 5: Drug History (DH)


    Find out what medications the patient is taking, including portion
    and how often they are taking them, for example: once-a-day,
    twice-a-day, once-a-week…etc.

    Step 6: Family History (FH)


    Gather some information about the patient’s family history, for
    example diabetes or cardiac history. Find out if there are any
    genetic conditions within the family, for example: polycystic kidney
    disease.

    Step 7: Social History (SH)


    This is the opportunity to find out a bit more about the patient’s
    background. Remember to ask about smoking and alcohol. You
    should also ask the patient if they use any illegal substances, for
    example: cannabis, cocaine…etc.
    Also find out who lives with the patient. You may find that they are
    the carer for an elderly parent or a child and your duty would be to
    make sure that if your patient is admitted to or stays in the
    hospital, they are not neglected or forgotten.

    Step 8: Allergies
    Ask if the patient is allergic to any kind of medications, food or
    environmental factors. 3
    Step 9: Review of Systems (ROS)
    Gather a short amount of information regarding the other systems
    in the body that are not covered in your HPC.
    The above example involves the CVS so you would focus on the
    others. These are the main systems you should cover:
    ▪️CVS ▪️Respiratory ▪️GI ▪️Neurology
    ▪️Genitourinary/renal ▪️Musculoskeletal ▪️Psychiatry

    Step 10: Summary of History


    Complete your history by reviewing what the patient has told you.
    Repeat back the important points so that the patient can correct
    you if there are any misunderstandings or errors.
    You should also address what the patient thinks is wrong with them
    and what they are expecting or hoping for from the consultation.

    Step 11: Patient Questions / Feedback


    During or after taking their history, the patient may have questions
    that they want to ask you. It is very important that you don’t give
    them any false information.

    By following this structured approach, you ensure that you gather


    comprehensive and accurate information to aid in diagnosis and
    management. Always adjust your questioning based on the
    patient's specific concerns and needs.

    4
    Vital Signs:

    Vital signs are measurements of the body's most basic functions.


    The four main vital signs routinely monitored by medical
    professionals and health care providers include the following:
    Body Temperature
    Pulse Rate
    Respiration Rate ( Rate Of Breathing)
    Blood Pressure

    Body Temperature:
    The normal body temperature of a person varies depending on
    gender, recent activity, food and fluid consumption, time of day,
    and, in women, the stage of the menstrual cycle. Normal body
    temperature can range from 36.5C degrees to 37.2C degrees for a
    healthy adult. We can take body temperature by using a glass or
    digital thermometer.
    A person's body temperature can be taken in any of the following
    ways:
    Orally: Temperatures can be taken by mouth.
    Rectally: Temperatures taken rectally tend to be 0.5 to 0.7F
    degrees higher than when taken by mouth.
    Axillary: Temperatures can be taken under the arm.
    Temperatures taken by this route tend to be 0.3 to 0.4F
    degrees lower than temperatures taken by mouth.
    By ear: A special thermometer can quickly measure the
    temperature of the ear drum, which reflects the body's core
    temperature (the temperature of the internal organs). 5
    By skin: A special thermometer can quickly measure the
    temperature of the skin on the forehead.

    Body temperature may be abnormal due to fever or Hypothermia.


    A fever is indicated when body temperature rises about one degree
    or more over the normal temperature and Hypothermia is defined
    as a drop in body temperature below 35C degrees.

    Pulse Rate:
    Pulse rate is a measurement of the heart rate, or the number of
    times the heart beats per minute. As the heart pushes blood
    through the arteries, the arteries expand and contract with the
    flow of the blood. Taking a pulse not only measures the heart rate,
    but also can indicate Heart rhythm and Strength of the pulse.
    The normal pulse for healthy adults ranges from 60 to 100 beats
    per minute. The pulse rate may fluctuate and increase with
    exercise, illness, injury or emotions.
    Females ages 12 and older, in general, tend to have faster heart
    rates than do males. Athletes, such as runners, who do a lot of
    cardiovascular conditioning, may have heart rates near 40 beats
    per minute and experience no problems.

    Taking Pulse:
    The pulse can be found on the side of the neck, on the inside of the
    elbow, or at the wrist. For most people, it is easiest to take the
    pulse at the wrist.
    6
    Respiration Rate:
    The respiration rate is the number of breaths a person takes per
    minute. The rate is usually measured when a person is at rest and
    simply involves counting the number of breaths for one minute by
    counting how many times the chest rises. Respiration rates may
    increase with fever, illness or other medical conditions. When
    checking respiration, it is important to also note whether a person
    has any difficulty breathing.
    Normal respiration rates for an adult person at rest range from 12
    to 16 breaths per minute.

    Blood Pressure:
    Blood pressure is the force of the blood pushing against the
    artery walls during contraction and relaxation of the heart. Each
    time the heart beats, it pumps blood into the arteries, resulting in
    the highest blood pressure as the heart contracts. When the heart
    relaxes, the blood pressure falls.
    Two numbers are recorded when measuring blood pressure. The
    higher number or systolic pressure, refers to the pressure inside
    the artery when the heart contracts and pumps blood through the
    body. The lower number or diastolic pressure, refers to the
    pressure inside the artery when the heart is at rest and is filling
    with blood.
    High blood pressure or hypertension, directly increases the risk of
    heart attack, heart failure, and stroke. With high blood pressure,
    the arteries may have an increased resistance against the flow of
    blood, causing the heart to pump harder to circulate the blood. 7

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