ASSIGNMENT

History Taking

BY

Dr.Noshair Adil ChBEMS,DEMS,PEMS

House Officer Qarshi Eastern Medicine Hospital Bahawalpur and General

Physician Sain Jee Trust Hospital Dunyapur

Member Punjab Medical Emergency Service

Department of Eastern Medicine & Surgery

College of Conventional Medicine

The Islamia University of Bahawalpur

CONTENTS Patient Bio-data Present Complains Past Illness Personal History Systemic Review Physical Examination Vitals Systemic Examination Differential Diagnosis Lab Investigation Diagnosis Treatment

PATIENT BIO-DATA Name-------- Sex---------- Age--------- Martial State-------- Occupation---------- Address -------

COMPLAINTS WITH DURATION Presenting Complains History of present Illness When patient is stop talk the question of a

physician is any other complain?? History told by the patient Relevant questionsThree main points are ask to patient When this disease Occur?? Where This disease Occur?? Why This disease occur??? These question helps the physician to know the

worse of disease. History of previous treatment

PAST ILLNESS Relevant to present Illness In this step Physician ask to the patient

any previous history of this disease occur in any age???

Infectious DiseasesIn this step Physician ask to the patient any

infectious disease like Pneumonia, Typhoid, Small Pox Chicken Pox and so other infectious Diseases

Oncology HistoryIn this step Physician ask to the patient any

history of Tumor or cancer

PERSONAL HISTORY What is the occupation of patient and

where he/she works Work Environment Which type of diet patient take daily Any Drug Addiction Drug allergies??? Surgical historyIn this step Physician ask to the patient

any previous history of operate or surgery??

SYSTEMIC REVIEW Central nervous system Respiratory system Cardiovascular system Liver & Biliary System Gastrointestinal Tract Urinary system Locomotary System Reproductive System

CENTRAL NERVOUS SYSTEM In this step Physician ask to the patient

about Headache Vertigo Migraine How your anger Contraction of Neck Muscle?? Any Anxiety Depression Convulsions

RESPIRATORY SYSTEM In this step Physician ask to the patient Cough Productive or Non-Productive Breathing Difficulty after normally

running Irritation Feel Sputum in throat when he/she

awake??? Cold and flue??? Pain in thoracic region??

CARDIOVASCULAR SYSTEM In this step Physician ask to the patient Tachycardia Bradycardia Pulse Blood pressure increase or decrease Pain in left arm???

LIVER & BILIARY SYSTEM Jaundice Hepatitis Stool color Mucus in stool Pain in right upper quadrant???

GASTROINTESTINAL TRACT Heart burn Nausea and vomiting after meal Diarrhea Constipation Abdominal pain Digestion is proper?? Appetite??? Thrust?? Flatulence

URINARY SYSTEM Urine color Pus in urine??? Blood in urine??? Burning urine??? Smell of urine??? Any renal pain?? What is the rate of urination???

LOCOMOTARY SYSTEM

Bone Movement is correct??? All Joints Move??? Any pain of Joints?? Muscle Fatigue??? Paralysis of Muscles??

PHYSICAL EXAMINATION

General Appearance Posture of patient mean how the

patient is sitting before you Orientation show how much the disease

is severe or mild Pain Radiating pain Pinning pain Burning pain Referred pain

VITALS Pulse Blood pressure Temperature Weight Height Anemia’s Cyanosis Jaundice

SYSTEMIC EXAMINATION G.I.TI. LipsII. Mouth & TeethIII. ThroatIV. TonsilsV. Mucus membrane

ABDOMINAL EXAMINATION TEST Inspection• Abdomen Shape• Umbilicus• Pulsation• Prominent veins• Movements of

abdominal walls

Palpation o Superficial

Palpationo Deep Palpation Liver Spleen Kidney Percussion Fluid Thrill Shifting dullness AuscultationBowel

Sounds………………

RESPIRATORY SYSTEM Inspection1. Shape of Chest2. Respiratory rate 3. Type of

Respiration

4. Scar or Rash

Palpation Trachea Apex beat Movement of chest

wall Spine Expansion of chest

CARDIOVASCULAR SYSTEM Arterial pulse Heart beat Blood pressure Vocal fermitus

SYSTEMIC EXAMINATION Nervous SystemConscious levelBehavior

Locomotary system

Lab Investigations

Provisional diagnosis

Treatment