BEDSIDE 1

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...........