HISTORY TAKING Dr.Moeen-uz-zafar

HEADLINES PATIENTS DATA PRESENTING COMPLAINTS HISTORY OF PRESENTING COMPLAINTS SYSTEMIC REVIEW PAST HISTORY PERSONAL HISTORY FAMILY HISTORY SOCIOECCONOMIC HISTORY

PATIENTS DATA NAME AGE SEX OCCUPATION ADDRESS RELIGION DATE/TIME/MODE OF ADMISSION

PRESENTING COMPLAINTS The Complaints which bring the patient to the doctor Recorded in chronological order e.g Abdominal pain …. 3 days Vomiting …. 2 days Fever ………. 1 day Use patients own words No leading Questions Recurrent symptoms can be recorded

HISTORY OF PRESENTING COMPLAINTS Symptoms are recorded in detail Always try to search when the patient was totally all right

DESCRIPTION OF SYMPTOMS PAIN SITE INTENSITY RADIATION SHIFT REFERRED PAIN DURATION CHARACTER e.g burning, aching, colicky, stabbing e.t.c PERIODICITY SPECIAL TIME OF OCCURANCE AGGRAVATING FACTORS RELIEVING FACTORS ASSOCIATED PHENOMENA

FEVER MODE OF ONSET RIGORS GRADE 36.6 – 37.2 C HYPERPYREXIA.. > 41.6 HIGH GRADE .. > 39 LOW GRADE .. > 38.5 HYPOTHERMIA .. < 35 PATTERN CONTINUOUS REMITTENT INTERMITTENT QUOTIDIAN TERTIAN QUARTAN RELAPSING UNDULATING STEP LADDER ASSOCIATED FEATURES

WEIGHT LOSS HOW MUCH IS LOST APPETITE ASSOCIATED FEATURES e.g FEVER , NIGHT SWEATS MASS DURATION SITE RECENT CHANGES PAIN FEVER PRESSURE SYMPTOMS

EDEMA GEN/LOCAL WHERE IT STARTED FIRST OTHER FEATURES e.g SOB, CHRONIC DIARRHEA, OLIGURIA DYSPNOEA (1) EXERTIONAL: DURATION ACTIVITY PPT. PROGRESSION PAROXYSMAL NOCTURNAL ORTHOPNEA H/O CHEST PAIN, RF

(2) DYSPNOEA AT REST (episodic) AGE OF ONSET FREQUENCY , SEVERITY and DURATION OF ATTACKS H/O ALLERGY F/H OF ASTHMA PALPITATION REST/EXERTION DURATION START OR TERMINATE GRADUALLY OR SUDDENLY ASSOCIATED SYMPTOMS e.g tremors, heat intolerence

COUGH DURATION FREQUENCY SEVERITY NIGHT or DAY DRY or PRODUCTIVE QTY, COLOUR and SMELL of SPUTUM HEMOPTYSIS

VOMITING DURATION FREQUENCY RELATION WITH FOOD ANY SPECIAL TIMING WT. LOSS VOMITUS .. QTY, COLOUR , SMELL HEMETEMESIS MELENA ASSOCIATED SYMPTOMS e.g int. obst.

DIARRHEA DURATION FREQUENCY QTY OF STOOL CONSISTENCY BLOOD/MUCUS HEMATOCHAZIA TENESMUS NOCTURNAL ASSOCIATED SYMPTOMS

CONSTIPATION USUAL BOWEL HABITS DURATION BLOOD IN STOL H/O ALTERNATING DIARRHEA DRUG HISTORY CHANGE IN EATING HABITS OTHER SYMPTOMS

DYSPHAGIA DURATION SOLID/LIQUID PROGRESSIVE SITE OF FOOD STICKING PAIN IN SWALLOWING ( ODYNOPHAGIA) LOSS OF WEIGHT VOMIT … DOES IT CONTAIN OLD FOOD PARTICLES PAST H/O HEART BURN

JAUNDICE PAIN RT HYPOCH. APPETITE DISTASTE COLOUR OF STOOL AND URINE ITCHING WT LOSS H/O OF BLOOD TRANSFUSION, CONTACT

HEADACHE SITE SEVERITY DURATION PROGRESSION CONTINUOUS/INTERMITTENT CHARACTER TIMING e.g raised ICP ASSOCIATED PHENOMENA e.g HALO + RED EYE

WEAKNESS/PARALYSIS MONO/HEMI/PARAPLEGIA COMPLETE( PLEGIA) INCOMPLETE ( PARESIS ) ONSET STATIC or PROGRESSIVE LOSS OF CONSCIOUSNESS FITS SPEECH H/O HTN , DM etc F/H of vascular disease

FITS/ CONVULSION AGE OF ONSET LOSS OF CONSCIOUSNESS GEN/LOCAL AURA TONGUE BITE FECAL/URINARY INCONTINENCE DURATION OF ATTACK AFTER SYMPTOMS

SYSTEMIC REVIEW GENERAL appetite; weight; sleep CVS SOB; palpitation; chest pain RESP. Cough; sputum; hemoptysis GIT nausea; vomit; abdominal pain; bowel habits; dysphagia UT flank pain; dysuria; frequency; nocturia NERVOUS SYSTEM weakness; headache; fits LOCOMOTOR joint pain; stiffness ENDOCRINE polyuria; polyphagia; heat intolerence EYE/ENT PROBLEMS

PAST HISTORY MEDICAL SURGICAL ALLERGIES DRUG SIMILAR HISTORY IN PAST BIRTH HISTORY and VACCINATION MENSTRUAL HISTORY menarche D/C regularity pain intermenst./ post coital bleed menopause

PERSONAL HISTORY DIET ADDICTION LIVING/WORKING CONDITION SEXUAL HABITS SPOUSE and CHILDREN PREVIOUS OCCUPATIONS

FAMILY HISTORY MAKE A FAMILY TREE ASK ANY FAMILY H/O HTN, DM etc

SOCIOECONOMIC CONDITION AVERAGE INCOME/ DEPENDENTS SOCIAL ENVIRONMENT