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HISTORY TAKING Dr.Moeen- uz - zafar

HISTORY TAKING Dr.Moeen- uz - zafar. HEADLINES. PATIENTS DATA PRESENTING COMPLAINTS HISTORY OF PRESENTING COMPLAINTS SYSTEMIC REVIEW PAST HISTORY PERSONAL HISTORY FAMILY HISTORY SOCIOECCONOMIC HISTORY. PATIENTS DATA. NAME AGE SEX OCCUPATION ADDRESS RELIGION

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HISTORY TAKING Dr.Moeen- uz - zafar

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  1. HISTORY TAKINGDr.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 36.6 – 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

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