15. What are the components of the history-taking process? Describe each component.
Taking a patient's history is the initial part of clinical examination and its main aim is to find out the patient's present problem. The history-taking process is a well-established and commonly used sequence.
1. History of presenting complaint. The main symptoms should be clearly defined as soon as possible, to find out the cause of admission or seeking medical advice. The onset, severity, progression, associated features or symptoms are all important. A special focus is also made on pains associated or not with specific organs.
2. History of present illness. The patient is requested to give an account of recent events in their own words which in this way may be recorded in the history sheet.
3. Systemic enquiry also known as the review of systems. The history is taken of the main symptoms of the major bodily systems.
4. Past medical history. Patients are asked about their previous medical/surgical diseases.
5. Drug history and allergies. Information is obtained on any medication prescribed, self-administered drugs.
6. Family history provides information about any predisposition to disease, and relevant information on relatives.
7. Social history. Information is collected about the patient's occupational, social, personal factors, such as habits, employment, housing, interests, sports, hobbies, physical exercise, the use of alcohol, tobacco, recreational drugs.
16. What organs and systems are reviewed during the examination and why? What general symptoms do you know? What disorders are they associated with?
Systemic enquiry also known as the review of systems is one of the main parts of history-taking process. The history is taken of the main symptoms of the major bodily systems:
General: mood, fatigue, anorexia, fever, night sweats, rashes, heat/cold intolerance.
Cardiovascular system: chest pain, palpitations.
Respiratory system: shortness of breath, cough, sputum, wheeze, hemoptysis.
Gastrointestinal system: nausea, vomiting, indigestion, abdominal pain, heartburn, change in bowel habit.
Genitourinary system: nocturia, frequency, incontinence, change in color/smell of urine, menstrual difficulties.
Central nervous system: headaches, weakness, dizziness, fits, faints, vertigo.
17. What are the recommendations for the effective communication of the doctor with the patient?
There are some recommendations for the effective doctor-patient communication:
Show the patient your attention.
Start by eliciting the presenting complaint.
Let the patient tell story in their own words.
Try not to interrupt.
Use the language which the patient understands.
Summarize the story for the patient to check, correct and add more relevant details.
Obtain the patient's history also from other sources of information.