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Name

First ask the patient if there is any thing Age


he/she wants to tell you about.
Marital status
Then run through common symptoms of 8. Systemic enquiry
all the systems, present in page 24 of 1. Patient Profile Education
MacLeod
Occupation
Residence
Smoking
Blood group, some times
Alcohol
Drugs
Chief
Diet
7. Social history 2. complaint
Exercise Life style
Occupational history
SOCRATES
Travel History Site
Sexual History Onset
Character

6. Family history 50% is Pain Radiation


Associated symptoms
Analysis of complaint Timing
What Drugs?
Exacerbating and relieving factors
Compliance 5. Drug history (DH)
History Taking Severity
Intolerance and allergies
analyzed according to symptom
50% not pain E.g. abdominal Onset and duration and
Ask about any previous operations or procedures associated signs
distention
Previous anaesthetics and treatments History of
present Please Carefully Question This Method
Vaccinations For Reliability and Resilience
3. illness
J - jaundice Position (site and radiation)
A - anaemia & other Character
haematological conditions
Past medical and Quantity (severity)
M - myocardial infarction
past surgical Transmission (associated features -
T - tuberculosis Another useful mnemonic that may be transmitted from index symptom)
Ask specifically about 4. history used to analyze any symptom is as
H - hypertension & heart disease these diseases; another Modifying factors (precipitating,
follows:
R - rheumatic fever helpful mnemonic is aggravating, relieving factors)
JAM THREADS Rate (onset, progression,
E - epilepsy
cessation, duration- as it is related
A - asthma & COPD to timing the word rate is used)
D - diabetes Rhythm (periodicity)
S - stroke Systemic enquiry in relation to complain
Management used to treat this complaint

History Taking.mmap - 10/5/2009 - Maen K A