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Hisotry taking for 4th year and above


Hisotry taking for 4th year and above

AS We Know History is the most important part in managing of a patient regardles of te complaint
here we will try to establish a simple,yet effective oulteline for history taking and at the same time aply these principles to various clinical situatins
lets start with parts of history
1-Profile
Includes Name,Age,Sex,Marital status,occupation,and place of living
dont underestimate the profile
Age and sex are so damn important for they can affect our DDX substancially
occupation also may have etiologic or medicolegal issues to do with an illness
place of living is very important,particularly when assesing a possible infectiou process due to different epidemeolgy of different microorganisms
examples: in a female with rash and joint pain SLE tops ur DDX list
while in a male with samilar symptoms u have to consider other things before SLE

a 60 year old smoker with chronic cough is more likely to have COPD while a 16 year old nonsmoker wit chrocnic cough is more likely to have asthma

a typical USMLE trick is to ask about patients from OHIO (think histoplasmosis) or colorado (think plague) with presentatons sggestive of weird infections!

2-cheif complaint(CC)
write down the complaint(s) of the patient in his own language
write the duration of each complaint

3-history of present ilness
this is the cream of the history
here we want to analyze the CC in order to reach a ddx
always think in this way:
-wut other symptomps that may accompany such a symtomp
example: if CC is abdominal pain always ask about N,V,Bowel habit and bleeding per rectum
if the CC is cough then ask about SOB,sputum,hemoptysis,chest pain

-wut may cause such a symptomp?
list the different etiologies in ur mind and ask a q or 2 to eliminate or support each
this is very important and we will illustarte how in examples ater on

-any relevant data from past medical history(PMH)- drug history (MH)and Family hisorty (FH)

PMH:
list chronic ilnesses,previuos seriuos acute ilnesses,blood transfusions and surgeries /procedures

MH
take note of all meds the patient is taking or has taken recently
record any known drug allergy

FH
draw the pedigree and list any chronic or genetic illness next to each individual,and cause and age of death next to the dead

social history
smoking
alcohol
note
alcohol consumption is different from alcoholism
the former is merely a habit while the latter is a disorder that has criteriae to diagnose
housing status
recent teavels
pets

ok this outline is useless if we dont illustrate how to use it so i will post a case or two but كمان شوي لاني زهقت من الطباعة

by
بعد التخرج


thanx dr ayyad for your precious infos
actually we all lack the methodology in taking history

waiting for practical cases

drpinkypanther's picture
drpinkypanther
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thannnnnnnnnnnnnnnnnnnnnx alot dr
but one thing can u put the complete word for the abbreviations u just write not all of them the important ones like
SOB
coz frankly alot of us dont know these abbreviations
coz alot of us start to read in english this year or didnt even start yet
thanx again
we r waiting 4the cases

drhanadi's picture
drhanadi
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Ok ....lets begin with an easy complaint
chest pain

profile
name:A.P
age:60
occupation:retired govement official
married w 3 kids
living in .....

CC chest pain of 3 week duration

HPI
now
we have pain in the history and we have to charactrize that pain
so we look for the 10 points related to any pain in the world
Site:and it is important to determine site as precisely as possible
chest pain: is it retosternal?generalized?localized

severity:best described on a scale of 10
in females w apparently severe pain comparison to labor pain maybe useful

nature: is it colicky,throbbing,crushing,stabbing
onset:was it gradual or acute
progression:is the pain always there or does it come and go
radiation:does it go to anywhere else
reliving factors:including positions ,maneauvers and medications
excerbating factors:such as excecise in chest pain,food in abdomianl pain

associated symptoms:fever nausea or vomitting

lets see the chest pain of this man and try to apply our scheme
site:centra=retrosteranl
severity:not really a pain,merely a discomfort
onset:gradual
progressin:present for few minutes
RADIATION : TO LEFT SHOULDER
relived by rest and nitroglycerin
excerbated by excercise and emotion

OBVIULSY THIS IS A TYPICAL CARDIAC DCHEST PAIN
IN A MAN WHO IS 60 YEARS OLD THE MOST LIKELY CAUSE IS CORONARY HEART DISEAES
SO NEXT STEP IS TO ASK ABOUT RISK FACTORS
SMOKING:INCLUDING AMOUNT AND HOW LONG
DIABETES:HOW LONG,MEDS AND IF CONTOLLED
HTN:HOW LONG,MEDS AND IF CONTROLLED
HYPERLIPIDEMIA:MEDS?
FAMILY HISORY OF PREMATURE CAD
(LESS THAN 55 YEAR OLD NON-SMOKER OR LESS THAN 65YEAR OLD FEMALE NONSMOKER)
IN A YOUNG PATIENT WE MAY BE CONCERNED ABOUT OTHE POSSIBLE CAUSES -SO WE MAY ASK ABOUT HEARTBURN,COUGH
ALSO IN THIS 60 YEAR OLD MALE A COMPLETE ASSESMENT OF CARDIAC FUNCTION IS NEEDED
BY HISOTRY
DYSPNEA?EDEMA?EXERCISE INTOLERANCE?
NOW E MOVE TO OTHER PARTS IN THE SAME ORDER

Dr_Ayyad
بعد التخرج

Dr. Hanadi,

the following file may be useful as a reference for medical abbreviations:

https://www.hakeem-sy.com/main/node/6407

KMG's picture
KMG
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there is a file at hakeem
very useful for history taking
it is a website
u can find it at downloads
it is fantastic !
good luck

HAWK's picture
HAWK
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brieve and useful
thanx

DAM's picture
DAM
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