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Past History

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Mohammad irfan
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12 views19 pages

Past History

Uploaded by

Mohammad irfan
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd
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Past history

MOHAMMAD IRFAN
What is history taking?

 Itis a process by which information is gained


by a physician by asking specific questions
to the patient with the aim of obtaining
information useful in formulating a diagnosis
and providing care to the patient
Importance of History Taking?

 Obtaining an accurate history is the critical


first step in determining the etiology of a
patient's illness.

Diagnosis is based on
 Clinical history
 Physical Examination
 Investigations
Alarge percentage of the
time (70%), you will be able
make a diagnosis based on
the history alone.
How to take a History?

 The basis of a true history is good communication


between doctor and patient.
 It takes practice, patience, understanding and
concentration.

Always listen to the patient they might


be telling you the diagnosis".
(Sir William Osler 1849 - 1919)
Approach to history taking
 Your look is Important
 YOUR DRESSING
Introduce yourself and create a Rapport
Be Alert and Pay full attention
 Ensure consent has been gained.
 Maintain privacy and dignity.
 Ensurethe patient is as comfortable as
possible
 Involve the patient in the history taking
process
 Communication skills and questioning techniques are
used to focus on current health condition, past
medical history, personal context, and emotional
context
 During the interview, the therapist should listen
carefully to what the patient says and ask key
questions that allow the patient to express feelings.
 The therapist’s communication (e.g., tone of voice,
choice of language) and non-verbal communication
(e.g., facial expressions, gestures, eye contact)
influences the patient’s level of comfort with the
interviewer and the overall outcome
 During the interview, the therapist should ask the
patient series of questions, using both open-ended and
closed ended questions
 Patient information can also be obtained from the
patient’s family or caregiver.
 For example, patients with central nervous system
(CNS) involvement and severe cognitive and/or
communication impairments and younger pediatric
patients will be unable to accurately communicate their
existing problems.
 “Ifin a bad mood or distracted during
the consultation, you can end up
making a history rather than taking a
history".
Components of History taking
 Patient's profile
 Chief complaint
 History of the present illness
 Past medical history
 Family history
 Socioeconomic history
 System Review
PAST HISTORY

 Pasthistory refers to the comprehensive


record of a patient's previous health issues,
treatments, surgeries, hospitalizations, and
other significant medical events that can
influence their current health status and
treatment.
Importance in Physiotherapy:

Diagnosis and Assessment


 Understanding underlying causes of current
conditions.
 Identifying comorbidities that may affect treatment
outcomes.

Treatment Planning:
 Tailoring interventions to individual patient needs.
 Avoiding contraindicated treatments.
Past Medical History
• Chronic Illnesses:
• Details of chronic conditions (e.g., diabetes,
hypertension, asthma, heart disease).
• Duration and severity of these conditions.

• Previous Injuries:
• Description of past fractures, dislocations, muscle tears,
or other musculoskeletal injuries.
• Long-term effects and risk of recurrence.
• Rehabilitation received and its outcomes.
• Surgeries:
• Types of surgeries undergone (e.g., orthopedic, cardiac,
neurological), dates, and outcomes.
• Specific details of surgical procedures and postoperative
complications.
• Rehabilitation protocols followed post-surgery.

• Hospitalizations:
• Reasons for past hospitalizations, treatments received, and
duration.
• Complications or follow-up care needed.
• Impact of prolonged immobility or bed rest.
Past Medication History:

Current Medications:
List of current medications, including dosage and duration.
Purpose of each medication and its impact on physiotherapy.

Past Medications
Medications previously taken for significant health issues.
Reasons for discontinuation and any adverse reactions.

Allergies:
Known allergies to medications or other substances.
Reactions experienced and management strategies.
THANK YOU

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