االسكندرية جامعةالطب كلية الباطنة االمراض قسم

The Art of History Taking (I)

History taking in medicine is the most important aspect of the medical examination .

Good and effective history taking can: 1 -Focus the attention to the system or systems affected.

2 -Give a better judgment of the severity and progress of the case. 3- Largely diagnose some diseases (e.g. epilepsy, migraine, and renal colic)

History taking is a special form of the art of communication: this is the beginning of of the good doctor-patient relationship:

1 -The patient should be put at ease and encourage him to talk freely. 2 -Make it clear that the patient has your whole attention.

3 -Common things towards good communication is to greet the patient ,by name if possible.

4 -Don't be angered or shocked by anything he/or she says5 -Patients must be allowed to tell their story in their own words and in

their own way . 6 -When the patient telling his story always watches his body language

(e.g. face expression, eyes, clenched fist, etc.).7 -Be a good listener

Medical History Taking Process :

1- Personal data.2- Chief Complaint. ( المريض ((شكوى

3- History of Present Illness.

4- Past Medical History.

5- Drug history and allergies.

6- Social history.

7- Family history.

I-Personal data:

1. Name.2. Age: Certain diseases are more common in special age groups

(e.g.infectious fever and congenital anomalies in childhood).3. Sex:

Certain diseases are related to sex (e.g. hemophilia in males).

Certain diseases are more common in special sex (e.g. rheumatoid arthritis and systemic lupus are more common in females).

4. Occupation: certain works may expose the individual to certain hazards (e.g. infection in medical staff, physical factors like radiation, and some occupational lung diseases).

5. Residence: e.g. Shistosomiases in country-side indwellers.6. Habits: e.g. smoking and alcohol intake.7. Marital state and number of children.

II- Chief or present Complaint : ( المريض :in patient's own words:( شكوى

- These are the symptoms that make the patient come to the doctor.- Try to define the main complaint and its duration.

- Most patients with long history tend to date them by events rather than by years.

- Multiple symptoms should be arranged chronologically (old to most recent).

III- History of Present Complaint: Ask the patient to tell you the story from

the beginning, ideally without interruption.

A -Your goal is: - To find out how exactly symptoms began. - In what setting they arose - How symptoms have evolved since initial onset

B -So, the history of the present condition should include:1- Mode of onset ( المرض بداية .(طريقة2- Course ( المرض .(مسار3- Duration.4- Negative data.5 –Review of other systems.

Types of onset: Sudden onset: seconds to minutes (e.g. vascular disease). Acute onset: hours to days (e.g. infections). Subacute onset: 1-2 weeks (e.g. chronic infections) Gradual and insidious onset: months to years (e.g. malignant

diseases).

Types of courses: Progressive: e.g. malignant and degenerative diseases. Regressive: e.g. self limited (common cold), or response to treatment

(acute infection and vascular accidents). Stationary: e.g. hereditary diseases. Paroxysmal attacks: e.g. bronchial asthma. Fluctuating (remissions and relapses: e.g. some chronic inflammation.

Negative data: These negative information are sometimes more important than positive information.

Review of other systems: other systems should be evaluated for evidence of any disturbances related to the present illness.

IV- Past Medical History : 1- History of previous illnesses: e.g.: - History of rheumatic fever in heart disease. - History of parasitic diseases like Schistosomiases. - History of high blood pressure.2- Trauma and surgical operations.3- Hospitalizations4- Blood transfusion.5- Pregnancies.6- History of travel abroad.

V- Drug history and allergies:1- Details of drugs taken: name, dosage, frequency, and length of usage2- Certain drug families known to cause problems (e.g. Aspirin for ulcers, steroids, etc.)3-Adverse effects to any drugs.4- Allergic reactions to any drugs: e.g. to penicillin or sulpha.5- Herbs and Herbal Medicines ( الطبية these can interact with - (االعشابmany drugs6- Traditional Medicines ( - والحجامة الصينية االبر البديل (الطب

VI- Social history: the social environment may affect the patient's health or may be affected by it.

1- The exact nature of his or her occupation.2- His domestic and marital relationships.3- His home surroundings.

4- Use of alcohol or tobacco.

5- Economic condition.

VII- Family history: certain diseases run in families (secondary to hereditary or environmental factors):

1- History of similar conditions or diseases in the other family members.2- History of consanguinity ( الوالدين بين القرابة .(درجة

Prepared by

Prof.Dr. Fathy Zakarya El Sewy

Head of the department

Prof. Dr. Tarek Moustafa Thabet