Exercise 1
History taking
:
components of a
•
Biographic data .
Family Health History
Complete Health •
chief complaint .
Drug History
Lifestyle and Health Practices /
History
.
History Of Present Illness
•
• Past Health History Personal and social History
importance ID
Obtaining an accurate history is the critical first step in determining the
etiology OF a patient 's illness
in
Diagnosis in medicine is based on :
1) clinical History
2) Physical Examination
3) Laboratory Tests
Types Of 1) Verbal communication
communication ID
open ended
-
questions -
needs explanation
ID Closed -
ended questions -
usually a 1- word answer ( yes or no )
2) Nonverbal communication
ID
Appearance
11> Altitude
11> Demeanor ID silence
11> Facial Expression
History Taking It>
Important steps in History taking
1) Introduce yourself
2) Explain the procedure
3) Assure confidentiality
4) Record the date and time of exam
components OF a 1) Demographics
complete Health •
Name •
Age
History •
Gender •
Ethnic Group
•
Marital status .
Address
2) Chief complaint
ID Presents the main problem
ID Note the answer in the patient 's own words
ID Note the associated complaints
3) History OF the present Illness
ID Includes Full details OF the history OF the main complaint
↳ Onset : sudden or gradual
ID Describes the progression of the complaint until examination
"
ID 7 Attributes of a symptom
"
SOCRATES
1) Location 1) Site -
where
2) Quality 2) Onset -
when it started
3) severity 3) Character -
description OF pain
4) Timing ( Onset duration ) 4) Radiation movement
, . Frequency -
5) which it
setting in occurs 5) Association -
other signs & symptoms
6) Influencing Factors 6) Time course -
patterns / duration
7) Associated manifestations 7) Exacerbating / Relieving Factors
triggers
-
8) severity -
intensity of pain
History taking
:
components of a
•
Biographic data .
Family Health History
Complete Health •
chief complaint .
Drug History
Lifestyle and Health Practices /
History
.
History Of Present Illness
•
• Past Health History Personal and social History
importance ID
Obtaining an accurate history is the critical first step in determining the
etiology OF a patient 's illness
in
Diagnosis in medicine is based on :
1) clinical History
2) Physical Examination
3) Laboratory Tests
Types Of 1) Verbal communication
communication ID
open ended
-
questions -
needs explanation
ID Closed -
ended questions -
usually a 1- word answer ( yes or no )
2) Nonverbal communication
ID
Appearance
11> Altitude
11> Demeanor ID silence
11> Facial Expression
History Taking It>
Important steps in History taking
1) Introduce yourself
2) Explain the procedure
3) Assure confidentiality
4) Record the date and time of exam
components OF a 1) Demographics
complete Health •
Name •
Age
History •
Gender •
Ethnic Group
•
Marital status .
Address
2) Chief complaint
ID Presents the main problem
ID Note the answer in the patient 's own words
ID Note the associated complaints
3) History OF the present Illness
ID Includes Full details OF the history OF the main complaint
↳ Onset : sudden or gradual
ID Describes the progression of the complaint until examination
"
ID 7 Attributes of a symptom
"
SOCRATES
1) Location 1) Site -
where
2) Quality 2) Onset -
when it started
3) severity 3) Character -
description OF pain
4) Timing ( Onset duration ) 4) Radiation movement
, . Frequency -
5) which it
setting in occurs 5) Association -
other signs & symptoms
6) Influencing Factors 6) Time course -
patterns / duration
7) Associated manifestations 7) Exacerbating / Relieving Factors
triggers
-
8) severity -
intensity of pain
