Case history taking

(Body Language )

Guidelines for taking case history

• Questions should be open ended (encourage)
• Guidance of conversation but not restricting
• Avoid leading questions (‘yes’ or ‘no’ answers)
• Clear & specific questions
• Ask one question at a time
• Cover various aspects of diseased organ
• Direct questions may be required sometimes
• Patient symptoms in his own words??

Special situations

• Infants under 5yrs; parent is interviewed
• Unconscious patients
• Under drugs effect
• Shying patients
• Emergency situation

In Emergency

• Fast the procedure but do not ignore it
• In case of emergency, obtain information from patient and/or bystanders

Classical history taking

Personal data

• Name:
• Full, accurate
• Communicate with patient
• Medico-legal aspects
• Age:
• Date of birth is better
• Growth and development is noted
• Certain diseases correlated with age
• Management techniques according to age

• Sex:
• Some diseases shows sex predilection
• Ethics & religious consideration
• Marital status: Infertility, pregnant…
• Contacts:
• Address: endemic diseases, follow up visits
• Phone
• Nearest kin

• Personal data

Occupation: Socio economic status

• Occupation: Socio economic status
• Race: Some certain diseases
• Religious: Certain considerations
• Date & type of admission
• Hospital number

• Personal data

Chief Complaint

• First symptoms that caused patient to seek medical advice
• Often:
• Pain
• Bleeding
• Abnormal function
• Observation of a lump