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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!