Case history taking

Many complaints

• Always record patient’s own words
• In order of severity
• In chronological order
• Present History
• Def.: Details of symptoms & their progress
• Should be well organized, clear, detailed

• It is important to get right back to the beginning of the problem

Present History

• Etiology (predisposing factors)
• Classical course of disease
• Any complications
• Loco-regional effect
• Systemic effect

Present history

• Negative information should be included if they contribute to the diagnosis or help exclude other possibilities

Past & medical history

Past & medical history

• Allergy & anemia
• Bleeding disorders
• Cardio respiratory disorders
• Drug history
• Endocrine disorders
• Fits & faints
• Gastrointestinal disorders
• Hospital admissions & surgeries
• Infections
• Jaundice & hepatic disease
• Kidney

Family history

• Ask about health or cause of death of patient’s parents, grandparents, brothers and sisters
• Previous similar illnesses in the family
• Potential for hereditary diseases

Reproductive history

• Infertility of both sexes
• Gynecological causes of abdominal pain
• Pregnancy & lactation
• Also ask about:
• Contraceptive use
• Venereal disease

Habits

• Smoker
• Athletics
• Appetite
• Alcohol
• Coffee
• Sexual

Sensitive Topics

• Alcohol or drug abuse
• Physical abuse or violence
• Sexual issues
• Psychiatric problems

Sensitive Questions Guidelines

• Respect patient privacy
• Be direct and firm
• Avoid confrontation
• Be nonjudgmental
• Use appropriate language
• Document carefully
• Use patient’s words as possible