1. History Taking A. A full case history covers: Personal details
Family history
Presenting complaint
Social and personal history
Past medical history
Patient ideas, concerns and expectation
Drug history
Review of systems

2. B. Case-Taking General Information or Personal details:
Personal details are entered in their records by a nurse or administrative staff.
A doctor may wish to check details such as:
Address
Date of birth
Occupation
Marital status

3. To check a patient’s occupation, a doctor may ask:
Do you work?
What do you do for a living?
What’s your occupation?
A patient may respond:

4. To check a patient’s marital status, a doctor may ask:
Do you have a partner?
What do you do for a living?
A patient may respond:

5. Social & Personal History:
Occupation
Housing
Personal habits (recreation, physical exercise, smoking)
Typical questions:
Where do you live?
Do you have children?
Are any of them at nursery or school?
Do you smoke?
How many a day?
Have you tried giving up?
What about exercise?

6. C. Presenting Illness: Case notes are kept for each consultation.
The Presenting Complaint section of case notes records the patient’s symptoms.

7. What’s brought you here today? Where exactly is the pain?
Starting the interview
Presenting Complaints
What’s brought you here today?
Where exactly is the pain?
How long have you had it?
Did anything special bring it on?
Is it worse at any particular time?
Does anything make it better or worse?
Have you any other problem?
Have you taken anything for it?

8. Drug History

9. Vocabulary: Over-the-counter:
drugs for which a prescription in not needed.
Laxatives: products that promote bowel movements.
Recreation:
refreshment of one’s mind or body after work through activity that stimulates; play, fun.
Compliance: the ability to take the dose at the right time and frequency.
allergy (to) noun allergic (to) adj
a body's abnormal reaction to certain foods or environmental substances (e.g. causes a rash)
Your son is extremely allergic to peanuts.

10. Asking about medication
Have you taken any medication for it?
Which tablets did you take?
Did the (tablets) help?
Do you use any over-the-counter remedies or herbal or homeopathic medicines?

11. Family History Typical questions:
Medical background of a person's family members.
The doctor is concerned about the patient’s family history of the disease. Such as:
Age
Health
Cause of death of parents, siblings (brothers and sisters), spouse (husband or wife), and children
Typical questions:

12. Exercises
1- Study the case notes. Write the questions the doctor may ask to obtain the numbered information.

13. Exercises
2- Write the doctor’s questions.

14. Exercises
3- Complete the sentences.

15. Exercises
4- Study the social history of Mr Black. Write the questions the doctor may ask to obtain the numbered information.

16. Exercises
5- Read the extract from a consultation. In the numbered questions (1-4), is the doctor encouraging the patient to talk about her ideas (I), her concerns (C) or her expectations (E)?.
1. I 3. C
2. I 4. E