HISTORY TAKING FROM THE PATIENT.

OBJECTIVE: EASILY TO DIAGNOSE A PATIENT.

Step's of History Taking towards the patient chapter 1.

Steps of history taking:- First of all, introduce yourself to the patient and ask permission to interview and examine the patient, (depends to the situation). If the patient is female, please ask a female staff nurse to assist you as chaperon. Developing a good rapport between a patient is essential for a good interview, and diagnose can made easily. This skills only come with practises. Ask the question relevant to the system suspected of being involved.

 1. Patients important data- name, address, age, sex, occupation, family burden's.

 2. History of presenting illness- ask the patient about the chief complain. ex: fever, since when (the duration of fever), condition of fever since started,(sweating too much,rigor,or fever in      phase's like malaria fever), try to find the source of infection.

3. Past medical and surgical history- ask the patients disease that patient having for a long time and short time such as diabetes mellitus, hypertension, tuberculosis, epilepsy, any heart and lungs disease, any operation that patient undergone, try to gather as much can. This information are very important to the diagnose because most of them can have secondary disease from their past diseases.

4. Drugs- Find out what drugs patients using for long and short time period. The purpose of uses the drugs. Any allergies from drugs. Currently on  medication. Obtain as much information as possible.

5. Smoking history and alcohol consumption- past and present.

6. Social and family history-marital status- home condition, ask any disease from the family, heritage diseases, any recent overseas travel.

7. Gynaecology- Find out information for female patient about their period and delivery types. 




Second Chapter will be coming soon, i will touch about the systems and chapter 3 will touch about psychical examination.