Session Structure

1
Session Structure

1. Introduction and Describing Aim Objectives
   20 min
2. Chief complaint 10min
3. History of present illness
   10min
4. Past medical history
   10min
5. Systemic enquiry 10min
6. Family history
   10min
7. Drug history 10min
8. Social history 10min

Pair Group and Role Play
2
Importance of History Taking

• Obtaining an accurate history is the critical
  first step in determining the etiology of a
  patient's problem.
• A large percentage of the time ) 70), you will
  actually be able make a diagnosis based on the
  history alone.

3
How to take a history?

• The sense of what constitutes important data will
  grow exponentially in future as you learn about
  the pathophysiology of disease
• You are already in possession of the tools that
  will enable you to obtain a good history.
• An ability to listen ask common-sense questions
  that help define the nature of a particular
  problem.
• A vast sophisticated fund of knowledge not
  needed to successfully interview a patient.

4
General Approach
5
Taking the history Recording

• Always record personal details NASEOMADR.
• Name,
• Age,
• Address,
• Sex,
• Ethnicity
• Occupation,
• Religion,
• Marital status.
• Date of examination

6
Complete History Taking

• Chief complaint
• History of present illness
• Past medical /surgical history
• Systemic review
• Family history
• Drug /blood transfusion history
• Social history
• Gyn/ob history.

7
CHIEF COMPLAINT
8
Chief Complaint

• The main reason push the pt. to seek for visiting
  a physician or for help
• Usually a single symptoms, occasionally more than
  one complaints eg chest pain, palpitation,
  shortness of breath, ankle swelling etc
• The patient describe the problem in their own
  words.
• It should be recorded in pts own words.
• What brings your here? How can I help you? What
  seems to be the problem?

9
Chief Complaint

• Cheif Complaint (CC)
• Short/specific in one clear sentence
  communicating present/major problem/issue. As
• Timing fever for last two weeks or since Monday
• Recurrent recurring episode of abdominal
  pain/cough
• Any major disease important e.g. DM, asthma, HT,
  pregnancy, IHD
• Note CC should be put in patient language.

10
Duration tips

• Exact duration.
• For how long you are ill.
• When you were completely normal.
• Is this complain for the first time or you have
  other episodes.

11
History of Present Illness

• Details progression, regression of the CC

12
History of Present Illness - Tips

• Elaborate on the chief complaint in detail
• Ask relevant associated symptoms
• Have differential diagnosis in mind
• Lead the conversation thoughts
• Decide weight the importance of minor complaints

13
History of Presenting Complaint (HPC)
14
History of Presenting Complaint (HPC)
15
History of Present Illness - Tips

• Avoid medical terminology make use of a
  descriptive language that is familiar to them
• Ask OPQRSTA for each symptom

16
Pain (OPQRST)
17
Past Medical Illness
18
Past Medical /Surgical History

• Start by asking the patient if they have any
  medical problems
• IHD/Heart Attack/DM/Asthma/HT/RHD,
  TB/Jaundice/Fits E.g. if diabetic- mention time
  of diagnosis/current medication/clinic check up
• Past surgical/operation history
• E.g. time/place/ what type of operation.
• Note any blood transfusion / blood grouping.
• H/O dental extractions/circumcision any
  exessive bleeding during these procedures.
• History of trauma/accidents
• E.g. time/place/ and what type of accident
• Any minor operations or procedures including
  endoscopies, dental interventions, bipsies.

19
Drug History
20
Drug History

• Drug History (DH)
• Always use generic name or put trade name in
  brackets with dosage, timing how long.
• Example Ranitidine 150 mg BD PO
• Note do not forget to mention
  OCT/Vitamins/Traditional /Herbal medicine
  alternative medicine as cupping or cattery or
  acupuncture.
• Blod transfusion.

21
Drug History

• bd (Bis die) - Twice daily (usually morning and
  night)
• tds (ter die sumendus)/tid (ter in die) Three
  times a day mainly 8 hourly
• qds (quarter die sumendus)/qid (quarter in die)
  four times daily mainly 6 hourly
• Mane/(om omni mane) morning
• Nocte/(on omni nocte) night
• ac (ante cibum) before food
• pc (post cibum) after food
• po (per orum/os) by mouth
• stat statim immediately as initial dose
• Rx (recipe) treat with

22
Family History

• Any familial disease/running in families e.g.
  breast cancer, IHD, DM, schizophrenia,
  Developmental delay, asthma, albinism.
• Infections running in families as TB, Leprosy.
• Cholera, typhoid in case of epidemics.

23
Social History
24
Social History

• Smoking history - amount, duration type.
• A strong risk factor for IHD
• Alcohol history - amount, duration type.
• Occupation, social education background, ADL,
  family social support financial situation.
• Social class.
• Home conditions as
• Water supply.
• Sanitation status in his home surrounding.
• Animals / birds in his/her house.

25
Social History smoking

• The most important cause of preventable diseases.
• Smoking history - amount, duration type.
• Amount packyear calculations.
• Duration continuous or interrupted.
• Any trials of quitting how many.
• Deep inhalation or superficial.
• Active or passive smoker.
• Type packs, self-made, Cigars, Shesha , chewing
  etc.

26
Social History smoking

• Ask the smoker whether he is willing to quit or
  not.
• Do not forget to encourage the smoker to quit
  whenever contacting a smoker as it is proved to
  increase quitting rate.
• If he is willing to quit, but can not, help him
  by NRT, buberpion.

27
Social History alcohol.

• Whether drinking alcohol or not.
• If drinking know whether it is healthy or not.
• Healthy alcohol use
• Men 14 units/week, not gt 4 units/session.
• Women 7 units/week, not gt 2 units/session.
• Dont forget that healthy alcohol use is
  associated with less IHD Ischemic CVA.
• Unhealthy alcohol use is associated with
  cardiomyopathy, CVA, Myopathies, liver cirrhosis
  CPNS dysfunction.

28
Social History alcohol.

• Note Do not advice patients or individuals , to
  drink for health, because of
• Religious cultural reasons.
• Possibility of addiction with its known health
  problems.

29
Other Relevant History

• Gyane/Obstetric history if female
• Gravida, para, abortions, SZ sections, antenatal
  care screens as for Hep B C.

30
Other Relevant History

• Immunization if small child
• Note Look for the child health card.
• Travel / sexual history if suspected STDs or
  infectious disease
• Note
• If small child, obtain the history from the care
  giver. Make sure talk to right care giver.
• If some one does not talk to your language, get
  an interpreter(neutral not family friend or
  member also familiar with both language). Ask
  simple straight question but do not go for yes
  or no answer.

31
System Review (SR)
32
System Review

• General
• Weakness
• Fatigue
• Anorexia
• Change of weight
• Fever/chills
• Lumps
• Night sweats

33
System Review

• Cardiovascular
• Chest pain
• Paroxysmal Nocturnal Dyspnoea
• Orthopnoea
• Short Of Breath(SOB)
• Cough/sputum (pinkish/frank blood)
• Swelling of ankle(SOA)
• Palpitations
• Cyanosis

34
System Review

• Gastrointestinal/Alimentary
• Appetite (anorexia/weight change)
• Diet
• Nausea/vomiting
• Regurgitation/heart burn/flatulence
• Difficulty in swallowing
• Abdominal pain/distension
• Change of bowel habit
• Haematemesis, melaena, haematochagia
• Jaundice

35
System Review

• Respiratory System
• Cough(productive/dry)
• Sputum (colour, amount, smell)
• Haemoptysis
• Chest pain
• SOB/Dyspnoea
• Tachypnoea
• Hoarseness
• Wheezing

36
System Review

• Urinary System
• Frequency
• Dysuria
• Urgency/strangury
• Hesitancy
• Terminal dribbling
• Nocturia
• Back/loin pain
• Incontinence
• Character of urinecolor/ amount (polyuria)
  timing
• Fever

37
System Review

• Nervous System
• Visual/Smell/Taste/Hearing/Speech problem
• Head ache
• Fits/Faints/Black outs/loss of consciousness(LOC)
• Muscle weakness/numbness/paralysis
• Abnormal sensation
• Tremor
• Change of behaviour or psyche.
• Pariesis.

38
System Review

• Genital system
• Pain/ discomfort/ itching
• Discharge
• Unusual bleeding
• Sexual history
• Menstrual history menarche/ LMP/ duration
  amount of cycle/ Contraception
• Obstetric history Para/ gravida/abortion

39
System Review

• Musculoskeletal System
• Pain muscle, bone, joint
• Swelling
• Weakness/movement
• Deformities
• Gait

40
SOAP