ISRAEL G.M

FWACP.

Socio-demographic Data Name

Age

Sex

Occupation

Marital status

Address

Religion

Tribe

Informant(s)- unconscious or paediatrics

Presenting Complaints(PC)The major health complaints and duration ( fever for past

4 days).

Fever for 2 days is completely diff from for 2 weeks

Cardinal Complaints

Usually two or three

Not constitutional symptom

Note duration e.g two days, weeks or years

History of the present complaints (HPC)

Details about the presenting complaints

Use patient’s own words

Usually form the body of the history, can ask about the following:

Hx of course of the complaints

Hx of associated conditions

Hx of possible etiology

Hx of complication

Hx of treatments

Past medical history (PMH)Major illnesses

Past blood transfusion

Past hospital admissions

Previous surgery/operations (sometimes distinguished as "Past Surgical History" or PSH)

Any current ongoing illness, e.g. diabetes, hypertension, Asthma, Peptic ulcer disease

The review of systemsProvide opportunity to globally look at other

symptoms omitted by the patient.

The review of systemsCardiovascular system:

Chest pain

Poor effort tolerance

Dyspnea

Orthopnea

Paroxysmal norcturnal dyspnea (PND)

Ankle swelling

Palpitations

The review of systems Respiratory system :

Cough

Breathlessness

Haemoptysis

Wheezing and chest tightness

Pleuritic chest pain

The review of systems Gastrointestinal system

Anorexia

Flatulence

Heart burn

Dysphagia/odynophagia

Abdominal pain

Vomiting

Bowel habit: Constipation/ Diarrheal (AL)

The review of systemsGenitourinary system

Frequency in urination

Pain with micturition

Urine color

Urethral discharge

Altered bladder control like urgency in urination or incontinence

The review of systemsNervous system

Headache

loss of consciousness

dizziness

vertigo,

speech and related functions like reading and writing skills and memory

Cranial nerves symptoms :Vision, diplopia, facial numbness, deafness, oropharyngial dysphagia, limb motor or sensory symptoms and loss of coordination

The review of systemsEndocrine system

weight loss

Polydipsia

Polyuria

increased appetite

Irritability

Tremor

The review of systems Musculoskeletal system

Bone or joint pain

Joint swelling or tenderness

Aggavating and relieving factors for the pain and any positive family history for joint disease

The review of systemsSkin

presence of skin rash

Changing skin rash

Recent change in cosmetics(soap and cream)

Family and social historyEspecially those relevant to the patient's principal

complaints.

Hypertension

Diabetes Mellitus

Seizure disorders (Epilepsy)

Asthma

Social history

Social history Living arrangements in the home

Occupation

Marital status

Number of children,

Drug use eg tobacco, alcohol, cocaine Amphetamine other recreational drug use.

Recent foreign travel

Exposure to environmental pathogens through recreational activities or pets.

Drug and Allergy history Regular and Acute Medications

prescribed by doctors

over-the-counter

Herbs

Allergies –

Medications

Food

Latex

other environmental factors

Obstetric and gynaecologyhistory

Last menstrual period

K= Number of days/ cycle

Regularity of cycle

Dyspareunia

Dysmennorhea

Menorrhagia

Use of oral contraceptive age.

Factors that prevents proper medical history taking Physical inability e.g unconsciousness

You need informant

Language barrier.

Speech abnormalities eg slurred

Poor Doctor patient relationship

Reluctance of the patient to disclose intimate or uncomfortable information. Eg sexual history

Computer-assisted history taking systems

Available since the 1960s.

Variable use across healthcare systems.

Advantages:

Avoid bias eg easy disclosure of unhealthy lifestyle behaviors.

Easy and high-fidelity portability to a patient's electronic medical records

Computer-assisted history taking systems Disadvantages:

Cannot detect non-verbal communication e.g computer wont notice anxieties

People may feel less comfortable communicating with a computer as opposed to a human.

Australia study; computer-assisted self-interview, 51% of people were very comfortable

35% were comfortable with it

14% were either uncomfortable or very uncomfortable with it