1. Principles of history taking

2. Reviewing the Chart:  The medical chart give you valuable information about past diagnosis and treatment  You should look at the identifying data (age, gender, address, marital status, health insurance, the medication list, the documentation of allergies)

3. Clinician’s Behaviors  As you observe the patient throught the interview, the patient will be watching you  You should be sensitive to those messages and manage them as well as you can  Posture, gesture, eye contact, and words can express interest, attention, acceptance, and understanding  The skilled interviewer seems calm and unhurried, even when time is limited

4. Clinician’s Appearance Cleanliness, neatness and a name tag are reassuring to the patient. Remember that you want the patient to trust you

5. Note taking You need to write down much of what you learn in a health history The Enviroment Make the setting as private as possible

6. Learning about the Patient’s iIlness Greeting the Patient  Greet the patient and introduce yourself by name  If this is the first contact, clarify your role, such as stating your status as a student and explaining your relation to the patient’s care  When other individuals are present, ask the permission of the patient to conduct the interview in front of them

7. The Patient’s Comfort Be alert to the patient’s comfort

8. Comprehensive history  Data and time of history: the date is important  Identifying data: including age, gender, maritual status and occupation  Source of history: such as patient, family, friend, officer, consultant, medical record  Chief complaints

9. Comprehensive history  Present illnes  Current medication: including dose and frequency of use  Allergies  Past history  Childhood illnesses: such as measles, rubella, mumps, whooping cough, chicken pox, rheumatic fever, polio

10. Comprehensive history  Adult illnesses: Medical 1.Diabetes mellitus 2.Hypertension 3.Hepatitis 4.Asthma 5.HIV

11. Comprehensive history  Adult illnesses: Surgical: include dates, indication, outcome Obstetric/ Gynecologic: inculde obstetric history, menstruation history, birth control, number and gender of partners, at-risk practises Psychiatric: include dates, diagnosis, hospitalisations, treatment

12. Current health status Tobacco (type used, amount and duration of use)  Alcohol (type used, amount and duration of use)  Drugs (type used, amount and duration of use)

13. Current health status  Exercise and diet  Immunisations: 1.Tetanus 2.Pertussis 3.Diphteria 4.Polio 5.Measles 6.Rubella 7.Mumps 8.Influenza 9.Hepatitis B

14. Family history Age and health, or age and couse of death of each immediate family members (parents, siblings, spouse, and children)  Date of grandparents and grandchildren may also be useful

15. Family history  Diabetes mellitus  Heart disease  Hypercholeterolemia  High blood pressure  Stroke  Kidney diseases

16. Family history  Arthritis  Anemia  Allergies  Asthma  Headaches  Mental illness

17. Family history  Tuberculosis  Cancer  Drugs  Epilepsy

18. Personal and Social History  Occupation and education  Home situation  Daily life  Leisure activites/hobbies

19. Present illness The principal symptoms should be discribed in terms of: 1.Location 2.Quality 3.Quantity and severity 4.Timing 5.Factors that have aggrevated or relieved them

20. Review of systems General:  Weight, recent weight change  Weakness  Fatique  Fever

21. Review of systems Skin:  Rashes,  lumps,  sores,  itching,  dryness,  color change  Hair and nails changes

22. Review of systems  Head: headache, head injury, dizziness  Eyes: vision, glasses, contact lenses, pain, redness, dryness, double vision, spots, flashing lights, glaucoma, cataracta  Ears: hearing, vertigo  Nose an sinuses: frequent cold, nasal stuffiness, hay fever, sinus trouble

23. Review of systems  Mouth and throut: condition of teeth, gums, bleeding gums,sore tonque, dry mouth, frequnt sore throats, hourseness  Neck: lumps, „swollen glands”,goiter pain  Breast: lumps, pain and discomfort  Respiratory: cough, sputum (color quantity) hemoptysis, dyspnea, wheezing, asthma, bronchitis, emphysema, pneumonia, tuberculosis,

24. Review of systems Cardiac:  heart trouble,  high blood pressure,  rheumatic fever,  heart murmurs,  chest pain or discomfort,  palpitations, dyspnoe, orthopnoe, paroxysmal nocturnal dyspnoe, edema

25. Review of systems Gastrointestinal:  Trouble swallowing  Heartburn  Appetite  Nausea  Vomiting  Regurgitation  Vomiting of blood

26. Review of systems Gastrointestinal: Bowel movements Color and size of stools Change of bowel habits Rectal bleeding Black tarry stools HemorrhoidsConstipationDiarrhea

27. Review of systems Gastrointestinal: Abdominal pain Food intolerance Jaundice Liver or gallbladder trouble hepatitis

28. Review of systems Urinary:  Frequency of urination  Polyuria  Nocturia  Burning or pain on urination  Hematuria  Urgency  Reduces caliber or force if the urinary stream  Incontinece  stones

29. Review of systems Genital: Female:  Age at menarche  Regularity  Frequency  Duration of periods  Amount of bleeding  Last period

30. Review of systems Genital:Femal:  Dysmenorrhea  Premenstrual tension  Age at menopausa  Itching  Sexually transmitted diseases  Number of pregnanycies  Number and type of delivery  Number of abortion

31. Review of systems Genital:Male:  Hernias  Testicular pain  Sexually transmitted diseases

32. Review of systems Periferla vascular:  Intermitten claudication  Leg cramps  Varicose veins  Past clots in the veins

33. Review of systems Musculoskeletal:  Muscle pain, weakness  Joint pain  Stiffness  Arthritis  Gout  Backache

34. Review of systems Neurologic: 1.Seizeres 2.Weakness 3.Paralysis 4.Numness or loss of sensation 5.Tremor

35. Review of systems Hematologic  Anemia  Easy bruising or bleeding  Past transfusion

36. Review of systems Endocrine  Thyroid trouble  Heat or cold intolerance  Excessive sweating  Diabetes  Excessive thirst or hunger  polyuria

37. Establishing Rapport  The initial contact with the patient sets the foundation for the relationship  Good interviewing technique allows patients to recount their own stories spontaneously  You should listen actively and watch for clues to important symptoms, emotions events, and relationships  You can than guide the patient into telling you more about the areas that seem most significant.  This is done by using direct questioning  Questionts should proceed from the general to the specific

38.  Sometimes patients seem quite unable to describe their symptoms without help  Offer multiple-choice answers” Is your pain aching, sharp, pressing, burning, shooting, or what?  Use lanquage that is undestandable and appropiate to the patient  Establishing the sequence and time course of the patient’s symptoms is important  You can encourage a chronologic account by such questions as” What than?” or „What happened next?”

39. Generating and Testing Diagnostic Hypotheses  As you learn about the patient’s story and the symptoms, you should be generating hypotheses about what body systems might be involved by a pathologic process  For example, leg pain, suggests a problem in the peripheral vascular, musculoskeletal, or nervous system

40.  1. Its location.Where is it? Does it radiate?  2. Its quality. What is it like?  3. Its quantity or severity. How bad is it?  4. Its timing. When did or does it start? How long does it last? How often does it come?  5. The setting in which it occurs, including enviromental factors, personal activities, emotional reactions.  6. Factors that make it better or worse.