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History Taking

The document outlines the typical sections included in a medical history taking: 1) Chief Complaint, 2) History of Present Illness, 3) Past Medical History, 4) Current Medications, 5) Allergies, 6) Social History, 7) Family History, and 8) Review of Systems. It describes the key information addressed in each section, such as onset, duration and location of symptoms in the History of Present Illness section and medical conditions of family members in the Family History section.

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Bosco Ainani
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87 views2 pages

History Taking

The document outlines the typical sections included in a medical history taking: 1) Chief Complaint, 2) History of Present Illness, 3) Past Medical History, 4) Current Medications, 5) Allergies, 6) Social History, 7) Family History, and 8) Review of Systems. It describes the key information addressed in each section, such as onset, duration and location of symptoms in the History of Present Illness section and medical conditions of family members in the Family History section.

Uploaded by

Bosco Ainani
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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History Taking

Insert:
History of presenting history order 1. **Chief Complaint:**
- The patient's primary reason for seeking medical attention.
- Stated in the patient's own words, using quotation marks.
- Should be concise and descriptive.

2. **History of Present Illness (HPI):**


- Detailed description of the chief complaint, including:
- Onset: When did the symptoms start?
- Duration: How long have the symptoms been present?
- Location: Where are the symptoms located?
- Quality: What do the symptoms feel like?
- Severity: How severe are the symptoms?
- Associated symptoms: Any other symptoms that are related to the chief complaint?
- Aggravating factors: What makes the symptoms worse?
- Relieving factors: What makes the symptoms better?

3. **Past Medical History (PMH):**


- A chronological list of all medical conditions that the patient has ever had, including:
- Diseases: Any diseases that the patient has been diagnosed with.
- Surgeries: Any surgeries that the patient has undergone.
- Injuries: Any injuries that the patient has sustained.
- Hospitalizations: Any hospitalizations that the patient has had.

4. **Current Medications:**
- A list of all medications that the patient is currently taking, including:
- Name of the medication
- Dosage
- Frequency
- Route of administration
- Reason for taking the medication

5. **Allergies:**
- A list of all allergies that the patient has, including:
- Name of the allergen
- Type of reaction (e.g., rash, hives, swelling)
- Severity of the reaction

6. **Social History:**
- Information about the patient's lifestyle, including:
- Occupation: What does the patient do for a living?
- Education: What is the patient's highest level of education?
- Marital status: Is the patient single, married, divorced, or widowed?
- Family structure: Who does the patient live with?
- Substance use: Does the patient use any tobacco, alcohol, or drugs?
- Sexual history: Any sexually transmitted infections (STIs) or high-risk sexual behaviors?

7. **Family History:**
- A list of the patient's family members and their medical conditions, including:
- Parents: Any diseases, surgeries, or injuries that the patient's parents have had.
- Siblings: Any diseases, surgeries, or injuries that the patient's siblings have had.
- Children: Any diseases, surgeries, or injuries that the patient's children have had.

8. **Review of Systems (ROS):**


- A systematic review of all the body systems, asking the patient about any symptoms that
they have experienced, including:
- General: Any fatigue, weight loss, or fever?
- Skin: Any rashes, lesions, or itching?
- Head and Neck: Any headaches, dizziness, or vision problems?
- Eyes: Any pain, redness, or discharge?
- Ears: Any pain, hearing loss, or tinnitus?
- Nose: Any congestion, runny nose, or nosebleeds?
- Throat: Any sore throat, hoarseness, or difficulty swallowing?
- Respiratory: Any cough, shortness of breath, or chest pain?
- Cardiovascular: Any chest pain, palpitations, or shortness of breath?
- Gastrointestinal: Any abdominal pain, nausea, vomiting, or diarrhea?
- Genitourinary: Any urinary frequency or urgency, dysuria, or hematuria?
- Musculoskeletal: Any joint pain, swelling, or stiffness?
- Neurological: Any headaches, seizures, or weakness?
- Psychiatric: Any depression, anxiety, or mood changes?
- Endocrine: Any thyroid problems, diabetes, or weight changes?

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