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History taking specific - Coggle Diagram
History taking specific
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Symptomatic, or systematic enquiry
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It should be remembered that the classification of symptoms by systems is one of convenience and is not absolute e.g. breathlessness may arise from disease of the cardiac, respiratory, renal or central nervous system.
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After the patient has given a general description of his illness, the system mainly involved will usually, but by no means always, be obvious.
General description
The history of the present condition may extend over days, weeks, months or even years and should be recorded chronologically.
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If there is doubt about the date of onset of the disease, the patient should be asked when he last felt quite well and why he first consulted his doctor.
The taking of an accurate history is the most difficult and, in the majority of medical diseases, the most important part of a consultation.
Dates may be quoted absolutely or relative to the date of writing e.g. five days ago; but if the latter system is used the date on which the history is written must be clearly shown.
Family history
Any similar or serious illness in parents, grandparents, siblings.
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