|Written by Dr.Md.Redwanul Huq (Masum)|
|Sunday, 23 December 2012 01:26|
The General History includes the following-
Particulars of the Patient:
- Age (Date of birth)
- Marital status
- Address (Temporary & Permanent)
- Date & Time of Admission (In In-Patient setting)
- Way of Admission (Through Outdoor or Emergency, In In-Patient setting) should also be included in general history
Presenting complaints (PC) / Chief complaints:
Chief complaints of the patient should be-
-A brief description having 3-4 complaints the chronology of which should be according to duration or severity,
– In the patient’s own words.
History of Present illness/presenting complaint (HPC):
- Starts as *According to the statement of the patient/patient’s attendant (In case of unconscious patients or children) he/she was reasonably well…..(the duration) back, then he/she has developed…….(First symptom)……then-
- Elaboration of the presenting complaints.
- Query about associated symptoms
- Exclusion of different probable causes producing all or some of the symptoms- by asking the patient negative symptoms
- Asking about presence of any lifelong disease like Diabetes Mellitus, Bronchial Asthma, Hypertension etc is also important in history of present illness.
Past medical history (PMH)/ History of past illness/ History of previous illness:
Asking the patient about-
- Past medical problems, e.g. Myocardial infarction, Jaundice, Tuberculosis, Rheumatoid arthritis, Epilepsy, Stroke etc
- Past psychiatric Illnesses (Depression, Schizophrenia etc.)
- Previous operations (Appendicectomy, Cholecystectomy etc.)
- Previous hospitalizations
- Previous injuries.
Drug history includes asking about-
- Current prescriptions (If present) (Including all doses and durations of drugs)
- Intake of over-the-counter drug(s)
- Intake of OCP, supplements, HRT (In case of female)
- Use of alternative medications
- Allergic or any other type of adverse reaction of drug(s).
- Family members(How many & who are they) are significant to know in family history
- Relevant illness in family members(parents/ siblings/ children )
- The current complaint(s) in them,( health, cause of death, age of death etc.)
- Presence of any hereditary illness like Diabetes mellitus, Bronchil asthma,Hypertension etc.
- Living circumstances- house or hat or bungalow or flat
- Details about sanitation, type of drinking water, way & place of taking meal.
- Social history also includes Social habits (if present).
Personal history includes-
- Date and place of birth
- Dietary habit
- Daily activities like washing, dressing, etc.
- Physical activity
- Level of education
- Smoking (If yes-type, number per day, total duration of intake)[1 pack year is equivalent of smoking 20 cigarettes/day for 1 year (e.g. if anyone smokes 20 cigarettes /day for 3 years, then he/she has a history of 3 pack years)]
- Alcohol (If yes-type, amount per day, total duration of intake).[As a rough calculation, an average pint of beer/standard glass of wine = 2-2.5units, alcopops = 1.5 units, a shot = 1 unit]
- Number and types of pets(If present)
- Foreign travel -place & way of living, any immunization/ prophylactic measurement before traveling (If relevant).
- Occupation (Present & past)
- Any exposure to hazardous agents.
- Times & types of immunization.
- Marital status (including quality)
- Health of the spouse / children
- Sexual activity.
- Sexually active/not
- Number of partners
- Any protective measure during sex
- Any difficulty during intercourse
- In case of male only-Painful erections (priapism), Abnormal bend on erection
- In case of female only- Contraception- on OCP/others, Pain during/after intercourse, Difficulty in conceiving, Pap smear- date & result of last smear’s also needed in sexual history.
Menstrual history (In case of female)
- Time of menarche
- Bleeding before puberty
- First day of last menstrual period (LMP)
- Length of menstrual cycles
- Length of menstrual period
- Regularity of periods
- Shortest and longest menstrual period
- Number of pads or tampons required during period
- Pain during periods
- Bleeding between periods
- Bleeding after intercourse
- If menopause-Time of onset, Presence of hot flushes, night sweating etc, Bleeding after menopause.
Obstetric history (In case of female)
- Number of children
- Age of the last child (ALC)
- Weights of children at birth
- Possibility of current pregnancy
- History of miscarriages and/or terminations (If present-time,cause,number)
- Problems during pregnancy (e.g. bleeding, abdominal pain,convulsions etc) or during delivery(e.g. prolonged labour, assisted delivery etc).
After taking the history, it’s useful to give the patient a summary of what he/she has told .