Medical History Taking

Kavya Liyanage

Why medical history taking is important?

▪ Patients do not come to the doctor with the diagnosis, but with symptoms.

▪ In order to diagnose what the patient has, we need to get a good relevance history of the patient.

▪ Also, history taking helps to find the cause for the patient’s condition.

Main Components of History Taking

▪ Introduction▪ Presenting complaint▪ History of presenting complaint▪ Past medical history▪ Past surgical history▪ Drug history and allergies▪ Family history▪ Social history

Introduction

▪ Name ▪ Age▪ Occupation▪ Residence

Presenting complaint

▪ This should be in the patient’s words. ▪ Symptoms and their duration

History of presenting complaint

▪ Onset, nature, course and duration of each symptom▪ When describing a pain, characteristics of pain is

described as SOCRATES– Site– Onset– Character– Radiation– Associated features– Timing (duration, course, pattern)– Exacerbating and relieving factors– Severity

Past medical history

▪ Medical details related to the current complaint▪ Important negatives also should be mentioned

Past surgical history

▪ Previous surgical procedures that the patient had undergone.

▪ The type of anaesthesia used and any complications

Drug history and allergies

▪ Significant drugs that the patient has been using▪ Allergies

Family history

▪ Family history about relevant diseases that can be transmitted genetically to the patient

Social history

▪ Whether the type of living of the patient has an impact on the patient’s condition

▪ Occupation▪ Marital status▪ Living circumstances▪ Smoking▪ Alcohol▪ Illicit drug use▪ Family support

Thank You!