Jan 4, 2013
Basic elements to cover in History Taking. (After getting all the basic details)
1. What brought you here? (Presenting complaint)
- Analysis of the chief complaint can be made at this stage. (My preference)
2. Is this the first time?
- If not the first time, then do not forget to ask about the past attack later.
3. When were you last well?....
- Analysis of chief complaint (if not done before)
- Chronologically from the moment he/she was unwell
- Always guide the patient by inquiring about CARDINAL SYMPTOMS, SYSTEMIC MANIFESTATIONS, and POSSIBLE COMPLICATIONS.
- Inquire about possible TRIGGERS, SPECIFIC CAUSES, RISK FACTORS, or SOURCES (if infection),..... At this stage sometimes we can get some of the past history or family history.
- How it affects his activity/life.
- How he managed the problem before coming to our side:
- E.g. Went to GP, treated as simple urti and only given tablet pcm.
4. If not first time, ask the details of the past attack(s).
- Compared to current presentation, how was the previous attacks?
- How did he manage the problem?
- If given long term medications: is he compliant? If not compliant, why?
- If scheduled for regular follow up: Compliant? or if defaulted what is the reason?
...will be updated later...........
Category: Clinical Medicine