1. HISTORY TAKING Dr.Moeen-uz-zafar

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

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

4. 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

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

6. 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

7. FEVER
MODE OF ONSET
RIGORS
GRADE – 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

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

9. 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

10. (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

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

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

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

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

15. 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

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

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

18. 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

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

20. 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

21. 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

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

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

24. SOCIOECONOMIC CONDITION
AVERAGE INCOME/ DEPENDENTS
SOCIAL ENVIRONMENT