HISTORY TAKING
 Identifying data    
Chief complaint      
History of present illness              
Past medical/surgical history                      
Drug history    
Family history                                  
Social history    
Systemic enquiry
1. Identifying data :
Always record personal details:
Name,
Age,
Address,
Sex,
Occupation,
Religion,
Marital status.
Date of examination
Reliability
2. Chief Complaint
Chief Complaint (CC):
Short/specific in one clear sentence communicating present/major problem/issue. As:
Timing – fever for last two weeks or since Monday
Recurrent –recurring episode of abdominal pain/cough
Note: CC should be put in patient language.

3. History of Present Illness
History of Present Illness - Tips
Elaborate on the chief complaint in detail
Ask relevant associated symptoms
Have differential diagnosis in mind
Lead the conversation & thoughts
Decide & weight the importance of minor complaints
History of Present Illness - Tips
The principal symptoms should be well-characterized, with descriptions of
(1) location,
(2) quality,
(3) quantity or severity,
(4) timing, including onset, duration, and frequency,
(5) the setting in which they occur,
(6) factors that have aggravated or relieved the symptoms,
(7) associated manifestations
(8) treatment
Ask OPQRSTA for each symptom
Pain (OPQRSTA)
Onset of disease
Position/site
Quality, nature, character – burning sharp, stabbing, crushing; also explain depth of pain – superficial or deep.
Relationship to anything or other body function/position.
Radiation: where moved to
Relieving or aggravating factors – any activities or position
Severity – how it affects daily work/physical activities. Wakes him up at night, cannot sleep/do any work.
Timing – mode of onset (abrupt or gradual), progression (continuous or intermittent – if intermittent ask frequency/ nature.)
Treatment received or/and outcome.
Are there any associated symptoms? .
4. Past history
Past Medical /Surgical History
Past medical
            IHD/ Heart Attack/ DM/ Asthma/ RHD, TB/ Jaundice/ Fits

Past surgical/operation history
                  E.g. time/place/ what type of operation.
 
Note any blood transfusion / blood grouping.

H/O dental extractions/circumcision & any exessive bleeding during these procedures.

History of trauma/accidents

Any minor operations or procedures including endoscopies, biopsy


5. Drug History
Drug History
Drug History (DH)
Always use generic name
           Example: Ranitidine 150 mg BD PO
 Note: do not forget to mention: OCT/Vitamins/Traditional /Herbal medicine & acupuncture.
Blood transfusion.
bd (Bis die) - Twice daily (usually morning and night)
tds (ter die sumendus)/tid (ter in die) = Three times a day mainly 8 hourly
qds (quarter die sumendus)/qid (quarter in die) = four times daily mainly 6 hourly
Mane/(om – omni mane) = morning
Nocte/(on – omni nocte) = night
ac (ante cibum) = before food
pc (post cibum) = after food
po (per orum/os) = by mouth
stat – statim = immediately as initial dose
Rx (recipe) = treat with

6. Family History
Any familial disease/running in families e.g. breast cancer, IHD, DM, schizophrenia, Developmental delay, asthma .
Infections running in families as TB, Leprosy.
Cholera, typhoid
7. Social History
Smoking history - amount, duration & type.
             A strong risk factor for IHD
Alcohol history - amount, duration & type.
Occupation
Home conditions as:
              Water supply.
              Sanitation status in his home & surrounding.
               Animals / birds in his/her house.

Don’t forget that healthy alcohol use is associated with less IHD & Ischemic CVA.
Unhealthy alcohol use is associated with cardiomyopathy, CVA, Myopathies, liver cirrhosis .
Other Relevant History
Gyane/Obstetric history if female
Gravida, para, abortions, antenatal care & screens as for Hep B & C.
9. System Review
This is a guide not to miss anything
General
Weakness
Fatigue
Anorexia
Change of weight
Fever/chills
Lumps
Night sweats
System Review
Cardiovascular
Chest pain
Paroxysmal Nocturnal Dyspnoea
Orthopnoea
Short Of Breath(SOB)
Cough/sputum (pinkish/frank blood)
Palpitations
Cyanosis
Gastrointestinal/Alimentary
Appetite (anorexia/weight change)
Diet
Nausea/vomiting
Regurgitation/heart burn/flatulence
Difficulty in swallowing
Abdominal pain/distension
Change of bowel habit
Haematemesis, melaena
Jaundice
Respiratory System
Cough(productive/dry)
Sputum (colour, amount, smell)
Haemoptysis
Chest pain
SOB/Dyspnoea
Tachypnoea
Hoarseness
Wheezing
Urinary System
Frequency
Dysuria
Urgency/strangury (severe pain on base of urethra)
Hesitancy
Terminal dribbling
Nocturia
Back/loin pain
Incontinence
Character of urine:color/ amount (polyuria) & timing
Fever
Nervous System
Visual/Smell/Taste/Hearing/Speech problem
Head ache
Fits/Faints/Black outs/loss of consciousness(LOC)
Muscle weakness/numbness/paralysis
Abnormal sensation
Tremor
Change of behaviour or psyche.
Pariesis.
Genital system
Pain/ discomfort/ itching
Discharge
Unusual bleeding
Sexual history
Menstrual history – menarche/ LMP/ duration & amount of cycle/ Contraception
Obstetric history – Para(no of live born)/ gravida(no of preg.)/abortion
Musculoskeletal System
Pain – muscle, bone, joint
Swelling
Weakness/movement
Deformities
Gait
PHYSICAL  EXAMINATION
1.)  General examination
2.)  Systemic examination
General Examination
Vital Sign (T, P, R, Bp)
Temperature
    Normal axillary T: 36~37?
    Fever:  T>37?
    Hypothermia: T<35?
Pulse
    Frequency: 60~100/min
    Rhythm: Regular
Respiration
    Normal: 14~20/min
Pallor (whitish discolouration)
Look for  mucous membrane in inner aspect of  lips, palm, eye.
Hb < 6 gm/dl --> pale palmar creases
Causes of pallor:
Anemia
Anxiety
Shock
Edema
     Jaundice(Icterus)
Yellowish discolouration of skin and mucous membrane is called jaundice.
Types of jaundice:
         1.) haemolytic jaundice
         2.) hepatocellular jaundice
         3.) post hepatic jaundice
Cyanosis
Bluish discoloration
     -Central ~~~ lateral aspect of under surface
                          of the tongue, lips (warm hands)
     -Peripheral ~~~ extremities  (cold hands)

Lymph nodes1

Size
Consistency
Tenderness
Matting
Mobility
Relation to surrounding structures.      
           Dehydration
It is a state of clinical condition due to decrease amount of water in the body.
Sites of examination:
    Eye: sunken eye
    Tongue: dry and thirsty
     Skin: skin pinch go back slowly or very slowly.
SYSTEMIC  EXAMINATION
Basic Examination Techniques
  inspection
  palpation
  percussion
  auscultation

Inspection
The areas to be inspected should be visible
   
Good lighting is important
   
The angle of the light can be used to advantage
   
Inspection and thinking with knowledge
   
Palpation
Light palpation
Deep palpation

Percussion Notes
Tympany: gas
Hyperresonance: increased gas in lung tissue
Resonance: lung tissue
Dullness: gas and tissue
Flatness: essential organ or fluid
Auscultation

Breath sounds, adventitious sounds
 
Heart sounds, murmurs
   
Bowel sound; bowel tones
Pulmonary Examination
 lung inspection
 
 lung palpation
 
 lung percussion

Lung auscultation
 
The Lung Inspection
Size and shape of thorax: barrel chest, flat chest

Respiratory frequency: normal-14-20, bradypnea<8, tachypnea>24
Depth and rhythm
   
Respiratory movement
             Normal: bilateral Symmetrical movements

   
The Lung Palpation
Chest expansion
 
Tracheal position
 
Vocal (tactile) fremitus