Medical History —

record the history as follows — In medical science The History taking is an art which comes by Experience

examination

• main present complaints
• history of present illness
• previous history of illness
• [females] menstrual history
• family history
• previous treatment history
• social and occupation history
• psychiatric history, etc.

GIT,Abdomen,Pelvic systems  —

pain–

• site, severity, localised or diffused, or where radiate and duration of pain, aggravating factors, releasing factors, etc.

appetite–

• + increase, or – decreased

vomiting–

• what is the frequency of vomiting, regurgitation, colour, tats, contains food or not, relation to pain, etc.

other–

• flatulence, water brash, dysphagia, etc.
• for lower intestine–

diarrhoea–

• what is the nature of motion, amount, relation to pain, appearance, colour, smell, etc.
• constipation–
• is there any constipation, since how long, related pain, site of pain, etc.

liver gall bladder–

• liver for jaundice–
• is there any itching in skin,colour of skin,history of injections, blood transfusions, etc.
• related pain to site,duration of pain, reliving and aggravating factors, etc.

cardio logical examination  —

dyspnoea–

• grade, severity, type  orthopnea, paroxysmal nocturnal, etc.

chest pain–

• main site of pain, character of pain, radiation, reliving and aggravating factors, nay medicinal history for pain [nitrates]

palpitation–

• regular and irregular, duration and site of palpitation, cough, dyspnoea, any blood in coughing etc.

respiratory system examination   —

cough–

• cough is very important, is it dry or wet productive, colour of it, dour of it, any history of allergy, medication, etc.

sputum–

• it is also very important in diagnosis, quantity, colour, smell, consistency, any blood or pus, timing in day and night, etc.

breathing–

• what kind of breathing, is patient dyspnoea, if yes then what grade of dyspnoea present, breathlessness, duration of onset and progressiveness, etc.

sound of chests–

• like wheezes, crackles, etc.

urinary examination   —

• urinary examination is one of the most important system to examine,
• because it is sometime the hidden cause for some unknown kind of fevers,
• .related pain to urination, site of pain,
• difficulty in maturation, colour of urine, smell of urine,
• drowsiness, vertigo, any kind of blood pus in urine, etc.

general examination

appearance

body builds

• nutrition, cachxia, obeys, etc.
• skin rashes, spider navi, pustules, patchier,
• spider nevi, pustules, body hair,
• deformities in body structure,
• temperature, pulse, respiratory,
• lymph node examination, etc.

eyes–

• is everything normal, like ptosis,
• oedema, anaemia, equality, equality in both eyes,
• nystagmus, strabismus, fundoscopy, endoscopy, etc.
• face—equality in emotion and facial movement, facial nerve, cranial nerve, etc.

upper-git–

• mouth and pharynx, breath and smell, lips- colour and pigmentation
• action, pharynx movement, neck movement, lymph glands

limbs–

• examination of arms and hands, fingernails –clubbing, any deformity, movement,
• blood pressure, lymphatic gland enlargement if any, legs and feet, oedema, varicocele, power, tone, sensations etc.

thorax–

inspection and palpation  –

• shape of chest is there any deformity, symmetry, pectus excavitum, carinatum, barrel shaped chest cage.
• respiratory rate, characteristics of respiration, pulsation, position and shape of trachea, position of apex beat, vocal fermatas.

percussion  —

• for normal resonance present or not, if not then what kind of resonance is it-
• hyper resonance,
• dullness,
• superficial or deep dullness, etc.

auscultation —

• used for heart sound,
• auscultation for beats,
• breath sounds, and vocal resonance, etc.

back–

• is there any problem with movement or shape of spine,or any deformity, etc.

abdomen–

inspection–

• abdomen size, is any distention,
• flanks, intestinal movement,
• peristalsis, pubic hair, is any sign for hernia, etc.

palpation–

• is any tenderness, rigidity, hyperesthesia, liver, gall bladder, kidney and spleen enlargement, urinary bladder, etc

percussion–

• masses, liver, spleen bladder, size enlargement, etc

auscultation–

• bowel movement sound, aortic bruit, etc.

extras—

• abdominal reflexes, impulses in inguinal sites during coughing,
• inguinal glands, genitalia, gynaecological examination, rectal examination, etc.
• that’s all it is the simple an easy way to take good history of a patient.