HISTORY TAKINGHISTORY TAKING

Dr.Moeen-uz-zafarDr.Moeen-uz-zafar

HEADLINESHEADLINES

PATIENTS DATAPATIENTS DATA PRESENTING COMPLAINTSPRESENTING COMPLAINTS HISTORY OF PRESENTING COMPLAINTSHISTORY OF PRESENTING COMPLAINTS SYSTEMIC REVIEWSYSTEMIC REVIEW PAST HISTORYPAST HISTORY PERSONAL HISTORYPERSONAL HISTORY FAMILY HISTORY FAMILY HISTORY SOCIOECCONOMIC HISTORYSOCIOECCONOMIC HISTORY

PATIENTS DATAPATIENTS DATA

NAMENAME AGE AGE SEXSEX OCCUPATIONOCCUPATION ADDRESSADDRESS RELIGIONRELIGION DATE/TIME/MODE OF ADMISSIONDATE/TIME/MODE OF ADMISSION

PRESENTING COMPLAINTSPRESENTING COMPLAINTS The Complaints which bring the patient to The Complaints which bring the patient to

the doctorthe doctor Recorded in chronological orderRecorded in chronological order e.ge.g Abdominal pain …. 3 daysAbdominal pain …. 3 days Vomiting …. 2 daysVomiting …. 2 days Fever ………. 1 dayFever ………. 1 day Use patients own wordsUse patients own words No leading QuestionsNo leading Questions Recurrent symptoms can be recordedRecurrent symptoms can be recorded

HISTORY OF PRESENTING HISTORY OF PRESENTING COMPLAINTSCOMPLAINTS

Symptoms are recorded in detailSymptoms are recorded in detail Always try to search when the Always try to search when the

patient was totally all rightpatient was totally all right

DESCRIPTION OF SYMPTOMSDESCRIPTION OF SYMPTOMS

PAINPAIN SITESITE INTENSITYINTENSITY RADIATIONRADIATION SHIFTSHIFT REFERRED PAINREFERRED PAIN DURATIONDURATION CHARACTER e.g burning, aching, colicky, stabbing e.t.cCHARACTER e.g burning, aching, colicky, stabbing e.t.c PERIODICITYPERIODICITY SPECIAL TIME OF OCCURANCESPECIAL TIME OF OCCURANCE AGGRAVATING FACTORSAGGRAVATING FACTORS RELIEVING FACTORSRELIEVING FACTORS ASSOCIATED PHENOMENAASSOCIATED PHENOMENA

FEVERFEVER MODE OF ONSETMODE OF ONSET RIGORSRIGORS GRADE 36.6 – 37.2 CGRADE 36.6 – 37.2 C HYPERPYREXIA.. > 41.6HYPERPYREXIA.. > 41.6 HIGH GRADE .. > 39HIGH GRADE .. > 39 LOW GRADE .. > 38.5LOW GRADE .. > 38.5 HYPOTHERMIA .. < 35HYPOTHERMIA .. < 35 PATTERNPATTERN CONTINUOUSCONTINUOUS REMITTENTREMITTENT INTERMITTENTINTERMITTENT QUOTIDIANQUOTIDIAN TERTIANTERTIAN QUARTANQUARTAN RELAPSINGRELAPSING UNDULATINGUNDULATING STEP LADDERSTEP LADDER ASSOCIATED FEATURESASSOCIATED FEATURES

WEIGHT LOSSWEIGHT LOSS HOW MUCH IS LOSTHOW MUCH IS LOST APPETITEAPPETITE ASSOCIATED FEATURES e.g FEVER , NIGHT ASSOCIATED FEATURES e.g FEVER , NIGHT

SWEATSSWEATS MASSMASS DURATIONDURATION SITESITE RECENT CHANGESRECENT CHANGES PAINPAIN FEVERFEVER PRESSURE SYMPTOMSPRESSURE SYMPTOMS

EDEMAEDEMA GEN/LOCALGEN/LOCAL WHERE IT STARTED FIRSTWHERE IT STARTED FIRST OTHER FEATURES e.g SOB, CHRONIC OTHER FEATURES e.g SOB, CHRONIC

DIARRHEA, OLIGURIADIARRHEA, OLIGURIA

DYSPNOEADYSPNOEA (1) EXERTIONAL:(1) EXERTIONAL: DURATIONDURATION ACTIVITY PPT.ACTIVITY PPT. PROGRESSIONPROGRESSION PAROXYSMAL NOCTURNALPAROXYSMAL NOCTURNAL ORTHOPNEAORTHOPNEA H/O CHEST PAIN, RFH/O CHEST PAIN, RF

(2) DYSPNOEA AT REST (episodic)(2) DYSPNOEA AT REST (episodic) AGE OF ONSETAGE OF ONSET FREQUENCY , SEVERITY and DURATION FREQUENCY , SEVERITY and DURATION

OF ATTACKSOF ATTACKS H/O ALLERGYH/O ALLERGY F/H OF ASTHMAF/H OF ASTHMA

PALPITATIONPALPITATION REST/EXERTIONREST/EXERTION DURATIONDURATION START OR TERMINATE GRADUALLY OR START OR TERMINATE GRADUALLY OR

SUDDENLYSUDDENLY ASSOCIATED SYMPTOMS e.g tremors, heat ASSOCIATED SYMPTOMS e.g tremors, heat

intolerenceintolerence

COUGHCOUGH

DURATIONDURATION

FREQUENCY FREQUENCY

SEVERITYSEVERITY

NIGHT or DAYNIGHT or DAY

DRY or PRODUCTIVEDRY or PRODUCTIVE

QTY, COLOUR and SMELL of QTY, COLOUR and SMELL of

SPUTUMSPUTUM

HEMOPTYSISHEMOPTYSIS

VOMITINGVOMITING DURATIONDURATION FREQUENCYFREQUENCY RELATION WITH FOODRELATION WITH FOOD ANY SPECIAL TIMINGANY SPECIAL TIMING WT. LOSSWT. LOSS VOMITUS .. QTY, COLOUR , SMELLVOMITUS .. QTY, COLOUR , SMELL HEMETEMESISHEMETEMESIS MELENAMELENA ASSOCIATED SYMPTOMS e.g int. ASSOCIATED SYMPTOMS e.g int. obst.obst.

DIARRHEADIARRHEA DURATIONDURATION FREQUENCYFREQUENCY QTY OF STOOLQTY OF STOOL CONSISTENCYCONSISTENCY BLOOD/MUCUSBLOOD/MUCUS HEMATOCHAZIAHEMATOCHAZIA TENESMUSTENESMUS NOCTURNALNOCTURNAL ASSOCIATED SYMPTOMSASSOCIATED SYMPTOMS

CONSTIPATIONCONSTIPATION

USUAL BOWEL HABITSUSUAL BOWEL HABITS

DURATIONDURATION

BLOOD IN STOLBLOOD IN STOL

H/O ALTERNATING DIARRHEAH/O ALTERNATING DIARRHEA

DRUG HISTORYDRUG HISTORY

CHANGE IN EATING HABITSCHANGE IN EATING HABITS

OTHER SYMPTOMSOTHER SYMPTOMS

DYSPHAGIADYSPHAGIA DURATIONDURATION SOLID/LIQUIDSOLID/LIQUID PROGRESSIVEPROGRESSIVE SITE OF FOOD STICKINGSITE OF FOOD STICKING PAIN IN SWALLOWING PAIN IN SWALLOWING ( ODYNOPHAGIA)( ODYNOPHAGIA) LOSS OF WEIGHTLOSS OF WEIGHT VOMIT … DOES IT CONTAIN OLD VOMIT … DOES IT CONTAIN OLD FOOD PARTICLESFOOD PARTICLES PAST H/O HEART BURNPAST H/O HEART BURN

JAUNDICEJAUNDICE PAIN RT HYPOCH.PAIN RT HYPOCH. APPETITEAPPETITE DISTASTEDISTASTE COLOUR OF STOOL ANDCOLOUR OF STOOL AND URINEURINE ITCHINGITCHING WT LOSSWT LOSS H/O OF BLOOD TRANSFUSION, H/O OF BLOOD TRANSFUSION, CONTACTCONTACT

HEADACHEHEADACHE SITESITE SEVERITYSEVERITY DURATIONDURATION PROGRESSIONPROGRESSION CONTINUOUS/INTERMITTENT CONTINUOUS/INTERMITTENT CHARACTERCHARACTER TIMING e.g raised ICPTIMING e.g raised ICP ASSOCIATED PHENOMENA ASSOCIATED PHENOMENA e.g HALO + RED EYEe.g HALO + RED EYE

WEAKNESS/PARALYSISWEAKNESS/PARALYSIS MONO/HEMI/PARAPLEGIAMONO/HEMI/PARAPLEGIA COMPLETE( PLEGIA)COMPLETE( PLEGIA) INCOMPLETE ( PARESIS )INCOMPLETE ( PARESIS ) ONSETONSET STATIC or PROGRESSIVESTATIC or PROGRESSIVE LOSS OF CONSCIOUSNESSLOSS OF CONSCIOUSNESS FITSFITS SPEECHSPEECH H/O HTN , DM etcH/O HTN , DM etc F/H of vascular diseaseF/H of vascular disease

FITS/ CONVULSIONFITS/ CONVULSION AGE OF ONSETAGE OF ONSET LOSS OF CONSCIOUSNESSLOSS OF CONSCIOUSNESS GEN/LOCALGEN/LOCAL AURAAURA TONGUE BITETONGUE BITE FECAL/URINARY FECAL/URINARY INCONTINENCEINCONTINENCE DURATION OF ATTACKDURATION OF ATTACK AFTER SYMPTOMSAFTER SYMPTOMS

SYSTEMIC REVIEWSYSTEMIC REVIEW GENERAL GENERAL appetite; weight; sleep appetite; weight; sleep CVSCVS SOB; palpitation; chest pain SOB; palpitation; chest pain RESP.RESP. Cough; sputum; hemoptysis Cough; sputum; hemoptysis GITGIT nausea; vomit; abdominal pain; bowel habits; nausea; vomit; abdominal pain; bowel habits;

dysphagiadysphagia UTUT flank pain; dysuria; frequency; flank pain; dysuria; frequency; nocturianocturia NERVOUS SYSTEMNERVOUS SYSTEM weakness; headache; weakness; headache; fitsfits LOCOMOTOR LOCOMOTOR joint pain; stiffnessjoint pain; stiffness ENDOCRINE ENDOCRINE polyuria; polyphagia; heat intolerence polyuria; polyphagia; heat intolerence EYE/ENT PROBLEMSEYE/ENT PROBLEMS

PAST HISTORYPAST HISTORY MEDICALMEDICAL SURGICALSURGICAL ALLERGIESALLERGIES DRUGDRUG SIMILAR HISTORY IN PASTSIMILAR HISTORY IN PAST BIRTH HISTORY and VACCINATIONBIRTH HISTORY and VACCINATION MENSTRUAL HISTORYMENSTRUAL HISTORY menarchemenarche D/CD/C regularityregularity painpain intermenst./ post coital bleedintermenst./ post coital bleed menopausemenopause

PERSONAL HISTORYPERSONAL HISTORY

DIETDIET ADDICTIONADDICTION LIVING/WORKING CONDITIONLIVING/WORKING CONDITION SEXUAL HABITSSEXUAL HABITS SPOUSE and CHILDRENSPOUSE and CHILDREN PREVIOUS OCCUPATIONSPREVIOUS OCCUPATIONS

FAMILY HISTORYFAMILY HISTORY

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

SOCIOECONOMIC CONDITIONSOCIOECONOMIC CONDITION

AVERAGE INCOME/ DEPENDENTSAVERAGE INCOME/ DEPENDENTS SOCIAL ENVIRONMENTSOCIAL ENVIRONMENT