2. INTRODUCTION
TO MEDICINE
HISTORY TAKING
Dr. Wasim Uddin
Consultant Physician
POF Hospital Wah Cantt

3. What is History?
• Getting to know the patient.
• Why has he come to
doctor/hospital?
• Getting as much detail about his
complaints as possible.

4. How to Start?
• Introduce yourself.
• Take patients permission.
• Stand on Patient’s Rt. Side of
bed.
• Listen carefully.

5. Patient’s Details
• Name
• Age
• Sex
• Address
• Occupation
• Date of Admission

6. Presenting Complaints
• Complaints which has brought
the patient to the doctor.
• Enumerate them in a
chronological order.
• Mention time.
• Use simple descriptive terms.

7. Example
•
•
•
•
Name
Age
Sex
Address
:
:
:
:
ABC
60 years
Male
WMC
• Occupation
:
Driver
• Presenting Complaints:
– Fever
:
– Cough
:
– Blood in sputum :
3 Months
6 wks.
3 days

8. History of Present
Illness
• Detail about each of the
presenting complaints.
• Use simple language.
• Avoid using diagnosis.
• Do not ask leading questions.

9. History of Present
Illness
• Onset of each complaint.
• Progress and course of
complaint.
• Aggravating or relieving factor.
• Associated symptoms.

10. History of Present
Illness - Example
• Pain
– Onset
– Site
– Character
– Radiation
– Course
– Aggravating/relieving factors
– Associated symptoms

11. History of Present
Illness
• Facilitate patients by simple
questions.
• Try to stop unnecessary
details.
• Be ready for any emotional
outburst.
• Never argue – postpone
interview if needed.

12. Past History
• Ask about significant
relevant past medical
history.
• Cut out on unnecessary
detail.

13. Treatment History
• Prescription drugs.
• Other medicines.
• Ask for any drug allergies.
• Treatment compliance.

14. Family History
• Relevant family history.
• Open ended questions.
• Know about genetics.
• Ask about other household
members.

15. Social History
• Occupation.
• Income – Other family
support.
• Type of house.
• Personal habits – Smoking,
drugs.
• Travel History.