INTRODUCTION TO MEDICAL HISTORY
You can download lecture in powerpoint format from here.
Medical history is the art of disease information taken from the patient. It helps physical examination and give information about lab tests. Medical history can be taken at different conditions:
Outpatient
Inpatient
Diagnosis is known: Pneumonia
Diagnosis is unknown: Chest pain
Acute disease: 2 days diarrhea
Chronic disease: 1 month diarrhea
Special conditions: Before operation
History should include patient’s all complaints chronologically. The patient physician relationship is special, patient should trust the physician. The physician should to tolerant, but must not permit any disrespectful behaviour.
Basic principles of history taking
Listening
Observation
First main complaint
Experience-theoretical informatiom
Sufficient time
Initiating time of complaint
Factors affection duration of complaint
Accompanying factors
Response to treatment
Its nature
You should introduce yourself before starting medical history. You should ask in order:
Personal information
Characteristics of complaint
Review of systems
Previous medical history
Family history
I will point two important points in medical history.
1.Your theoric knowledge must be good so you know what to ask. You must be able to understand the relationship between unrelated findings.
2.Review of systems
Main purposes:
Evaluate all systems
Check missed signs or symptoms
Absence of some findings are as important of their presence
Any detected sign should be evaluated in details
In summary
The present complaint
The history of the present complaint
Remaining questions of abnormal system
Review of systems
Past medical history
I recommend you 6 videos to watch and listen, 4 English, 2 Turkish.
Healthy days without corona.
Prof. Dr. Tekin Akpolat
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