How to take the History Establish a rapport with patient introduce yourself. Initiate by asking – what made him to seek medical advice. Listen without interruption. Wait for answers before asking another question.
Don’ts of history taking Do not interrupt the patient. Do not use medical terminology. Do not ask irrelevent questions Do not ask leading questions. Do not be abrupt or impatient.
The Present Complains Ask the patient to tell you what made him to seek medical advice. Record the answer in patients words.
History of Presenting Complains Details of the history of the main complaints. - when did it start - what was the first thing noticed - progress since then - ever had it before.
History of Presenting Complains S – Site O – Onset C – Character R – Radiation A – Association T – Timing/Duration E – Exacerbating & alleviating factors S - Severity
Direct Questioning Specific questions about the diagnosis you have in mind. - Risk factors. - Review of relevant system.
Past Medical History Drug History Family History Social History Habits
Chronic Arterial Insuffciency: Intermittent Claudication Site – depends on the level & extent of arterial disease - Cramp like pain - Consistantly reproduced by same level of exercise - Completely & quickly relieved by rest - Claudication distance
Rest Pain - continuous severe pain, aching in nature - occurs in distal part of foot - often relieved by putting the leg below the level of heart - movement or pressure causes exacerbn.
Ulcer – area of discontinuity of surface epithelium Gangrene – Dead tissue - Duration, Site. - what drew the patient’s attention to the ulcer - other symptoms - progression - persistance - multiplicity