Taking History of the Patient

Table of Contents

Taking History of the Patient (PEX 2.3.2: Take history of the patient)

Objectives:

Identify the requirements for assessing the patient.
Prepare the requirements for assessing the patient.
Carry out assessment of the patient.

Definition of Data Collection (from 3.1):

Data collection consists of gathering information about the patient in order to develop a "data base" which can be analyzed in various ways depending on the intended use. There are two types of data:

Subjective data (Symptoms felt by the patient)
Objective data (Observable signs)

Sources of Data:

Patient (primary source of data)
Family members and significant others
Various patient's records (medical charts, previous notes)
Other members of the health team.

Requirements :

Top Shelf (Observation Tray):

Thermometer
Watch (with seconds hand)
Stethoscope
Blood pressure machine (Sphygmomanometer)
Neurological tray (Torch light/penlight, Spatula, Patella hammer, Otoscope, Tuning fork, Gallipot with cotton swabs/gauzes, Skin pencil, Snellens chart, Ophthalmoscope, Atropine 1% eye drops)
Auroscope set (Jobson Horne ring probe, Wool and applicator, Dissecting aural forceps)
Sterile throat swab
Dental mirror laryngoscope
Nasal speculum
Alcohol swabs
Lubricant
Drape
Vaginal speculum
Disposal pads

Bottom Shelf:

Record forms (History forms, assessment charts)
Disposable gloves
Specimen bottles

At the side:

Weight scale (electronic or sling scale)
Measuring tape
Ruler
Record chart
Screen (for privacy)
Examination table (if needed)
Hand washing equipment

Procedure (Taking History of the Patient):

Steps	Action	Rationale
1.	Observe the general rules (e.g., introduce yourself, wash hands).	Promotes professionalism, hygiene, and sets a positive tone.
2.	Explain the purpose of taking the history and ensure patient privacy by using screens or a private room. Build rapport and a therapeutic relationship with the patient.	Providing information fosters cooperation and helps reduce anxiety. Respecting privacy is fundamental.
3.	Take history in the following order, encouraging the patient to speak freely and using open-ended questions: Biographical/Personal Information: Name, age, tribe, address, occupation, religion, marital status, level of education, next of kin, relationship to next of kin, telephone number patient or and next of kin, nearest health facility.	To create a therapeutic relationship, identify the patient, for legal purposes and follows up.
4.	Presenting/Main Complaint: Establish the reason for seeking health care, focusing on: - Onset (When did it begin; is it better, worse, or the same since it began). - Character (How does it feel, look, smell, sound, severity etc). - Anatomic location (Where is it? Where does it radiate). - Duration (How long it last/ does it recur). - The setting in which it occurs. - Pattern or precipitating factors (What makes it worse or better). - Associated factors (What other symptoms do you have with it?)	A detailed description of the concern helps the nurse to gain an insight into the problem and is a basis to develop a nursing care plan for managing the patient.
5.	Past Medical History: Inquire about past diseases or recurrent conditions (e.g., sickle cell, asthma, malaria, kidney diseases, diabetes, STIs, poliomyelitis, rickets, any past infection or hospitalization).	To identify previous conditions or complications that may be aggravating the presenting complaint.
6.	Past Surgical History: Inquire about accidents, injury, blood transfusion history, and reasons for past surgeries/fractures.	To understand previous health events that may impact current condition or care.
7.	Past Medications Received: Ask about patient's response to past/current medications, whether still on medication, any allergies (including food and environmental), use of home remedies or herbs.	To establish the past/current medication use, identify allergies, and assess potential side effects.
8.	Social History: Inquire about alcohol and tobacco consumption, source of income, housing conditions, source of water, marital status, number of children, health of children and spouse, occupation and environment, sexual activities, sex partners, and family planning.	To identify risk of conditions or diseases related to stated social history and understand the patient's living situation.
9.	Family History: Establish if both parents are dead or alive (if died, what was the cause?). Inquire about spouse, siblings (number, illness), and children (age, illness). Ask about inherited diseases in the family.	To find problems related to daily living activities and general wellbeing, and identify genetic predispositions.
10.	Gynecological History (for female patients): Inquire about menarche (age of first period), menstrual cycle (number of days, amount of blood, regularity), date of last menstrual period (LMP), obstetric history (number of pregnancies, births, abortions, living children, complications), use of contraception, history of sexually transmitted infections (STIs), vaginal discharge, tumor history (cervical/uterine cancer), pap smear history (if applicable).	To rule out gender-related conditions and inform care related to reproductive health.
11.	Male History (for male patients): Establish male fertility related conditions, prostate problems (e.g., BPH), history of STIs, scrotal or penile problems.	To rule out gender-related conditions and inform care related to reproductive health.
12.	Systems Review: Ask about symptoms related to each body system (e.g., respiratory, cardiovascular, gastrointestinal, genitourinary, neurological, musculoskeletal, integumentary).	To identify additional symptoms or problems the patient may not have mentioned initially.
13.	Thank the patient for their cooperation.	To conclude the interview respectfully.
14.	Document the complete history accurately and legibly on the patient's chart/form.	For continuity of care and legal record.

Special Senses Assessment :

(Note: This seems like a sensory assessment included in the section)
Bottle for cold and hot water (to test temperature sensation).
Bottles with distinctive smelling liquids e.g. lavender (to test olfactory sense).
Bottles with salt, sugar, bitter, and sour substances (to test taste sensation).

Nurses Revision

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