History Taking Lesson -1 - TRUE NEWS

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Sunday, November 25, 2012

History Taking Lesson -1

                           History  Taking
Particulars of the patient :
Sex: male /female:
Marital status:
Present address:
Permanent address:     
Unit:                                   Ward :                                                                            Bed no:
Date of admission:
Date of examination:

Source of history : patients/relatives/others.
Chief complaints / presenting complaints:
History of present illness:
                      Elaboration of the chief complaints, (mode of onset, progression , etc)
                       Systemic inquiry ,drug history during this illness,
                       (long term medicine anti-hypertensive,  Anti- diabetic,anti-thyroid,bronchilal asthma , etc)
History of past illness:
Illness relevant to the present  illness ,H/O Hospitalization, H/O Operation,
Social & Occupational History:
Ø  Socio-economic status:
Ø  Education:
Ø  Monthly income:
Ø  Family members:
Ø  Housing:
Ø  Sanitation:
Ø  Water supply:
Ø  Occupational exposure:
Family History: (TB,HTN,DM,IHD,relevant to the chief complaints).
Personal History:
Ø  Habits:smoking,addiction.
Ø  Personal hygiene:
Ø  H/O exposure to venereal disease.

Menstural & Obstetric History (in female patient)
Ø  Menstural period
Ø  Menstrual cycle
Ø  LMP (last day of menstrual period)
Ø  Para(no of child birth)
Ø  Gravid(if pregnant)
Ø  Menarche
Ø  Menopause

Immunization & Overseas Travels:
H/O EPI vaccination, Hepatitis B vaccination. Etc.

General Examination:
A.       Appearance:
B.       Body-built:
C.       Co-operation:
D.       Decubitus :
E.       Nutritional status:

1.       Anaemia
2.       Jaundice
3.       Cyanosis
4.       Clubbing
5.       Dehydration
6.       Oedema
7.       Koilonychias
8.       Leukonychia.
9.       Thyroid gland
10.     Engorged neck vein
11.     Pulse:
a)       Rate
b)       rhythm,
c)       volume,
d)       character,
e)       condition of the vessel wall
f)        radio-femoral delay:
g)       symmetry.

12.     Blood pressure
13.     Respiratory rate : (12-18 per minute normally)
14.     Temperature
15.     Lymph node:
Ø  Groups of involved
Ø  Number
Ø  Size
Ø  Consistency
Ø  Matting/discrete
Ø  Tenderness
Ø  Mobility
16.     Overlying skin    local temperature , discharging sinus.
Ø  Skin condition:
Ø  Hair distribution
Ø  Pigmentation
Ø  Skin eruption
Ø  spider naïve
17.     bony tenderness:
18.     gynaecomastia:

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