History taking and physical examination

KEY ELEMENTS Introduce yourself,(name and position) Rapport with patient, Beginning start with open ended questions, Follow structural format, End, Summarize and have you got anything else to say,

Open ended questions Tell me what made you to come here Tell me more about, What do you think about, Is there any thing else to tell,

Identification data Name, Age, Sex, Race, Date of birth, Address, Referrals used,

Standard format Chief complaints(chronological order) History of Present illness, Past history, Drug history/allergies Family history Social and occupational history,

Chief complaints Example, Fever-2 weeks, Productive cough-1 week, Vomiting -2 days, Fatigue-1day,

Present illness Fever, Duration/Onset, Diurnal variation, Nature of fever, Associated factors, Aggravating and relieving factors,

Example (FEVER)Present illness Fever since 2 weeks, to begin with it was mild fever, present through out the day, Associated with chills and rigors, Relieves after taking Tylenol, No skin rashes, No seizures/convulsions, No diarrhea/no abdominal pain,

Past history No similar complaints in the past, No history of hospitalization No previous surgeries, No history of Diabetes/Hypertension No history of epilepsy No drug allergies, Not on medications

Family history Any illness run in your family? Similar history in the family, Parents and siblings suffering with any chronic illness, You should be able to collect relevant family history depending upon the present illness. Example, Patient has come due anemia, Try to R/O sickle cell, thalasemia/G6PD deficiency

Or patient has presented with febrile Convulsions, R/O family history of epilepsy, Or present with infective disease like Tuberculosis, R/O family history of T.B

Social and occupational history Smoking, (how many pakets/day) Alcohol(What he drinks, how much) And drug addiction Exposure to chemicals, The duration of the exposure,

Pediatric cases Includes, Pregnancy and illness during pregnancy, Is the born with full term and normal delivery/any L.S.C.S Developmental history,(milestones) Immunization history

General examination Whether patient is conscious, Oriented to place/person/time, His built, nourishment, Dehydrated, depressed, distress, Anxious,

VITAL SIGNS Pulse rate, Blood pressure Respiratory rate, Temperature,

Look for signs of Anemia, Jaundice, Clubbing Cyanosis

Systemic examination Involved system should be the first priority. The other system must be examined later. Differential diagnosis Final diagnosis Investigations, Treatment