History Taking Dr. Muhammad Wasif Haq

How Do We Diagnose A Patient? History Examination Investigations Accurate history is almost half the diagnosis.

Before You Begin Observe the way patient enters the hospital O.P.D. Significance? Introduce yourself; your name, your position. Try not to ask leading questions or medical terminologies. Do not rely upon patient when he/she uses medical terms, clarify. Keep your attention and attitude focused.

Parts of History For convenience, let’s divide history taking into following segments Patient’s Biodata (Name, Age, Sex, Address, Contact Number, Marital Status, Occupation and Hospital record Number) Presenting Complaint (Main reason why patient has come to you) should be in patient’s own words. History of Presenting Complaint (How did problem start? Since when? Has it increased or decreased? What are associated symptoms?)

Parts of History When more than 1 symptom, write in order of chronological order, the very recent problem first followed by the older complaint. Medical History ( Any systemic disease? Any operation or surgery? History of blood transfusion) Family History (Health status of Parents, Siblings, Husband/wife) Drug History/ Allergies ( Name of drugs being regularly taken, duration, dose, purpose) What to do if patient has allergy? Can you name few allergy causing drugs?

Parts of History Social History ( Occupation? Income) Habits (Cigarette smoking? What to note? Addictive habits) Past Dental History ( Any previous procedure performed? How was the experience? Any troubles/ mishaps?)

Template: Pain Patient has pain in teeth. Questions to ask? Site, Time and mode of onset, Duration, Severity, Nature/Character/Type, Radiation, Progression, Relieving and aggravating factors?

Template: Sensitivity Patient has sensitive teeth Questions to ask: Since when? Are they more sensitive to either cold food or hot foods or not? Does sensitivity causes pain? Which type of foods cause sensitivity? How long does sensitivity last?

Template: Bleeding Gums Patient complains of bleeding gums. Questions to ask: Since when? Do they bleed upon brushing or eating hard foods or spontaneously? Sensitivity? Pain? Do you have problems in controlling bleeding from minor wounds?

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