Medical History —
record the history as follows — In medical science The History taking is an art which comes by Experience
- 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 —
- site, severity, localised or diffused, or where radiate and duration of pain, aggravating factors, releasing factors, etc.
- + increase, or – decreased
- what is the frequency of vomiting, regurgitation, colour, tats, contains food or not, relation to pain, etc.
- flatulence, water brash, dysphagia, etc.
- for lower intestine–
- what is the nature of motion, amount, relation to pain, appearance, colour, smell, etc.
- 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 —
- grade, severity, type orthopnea, paroxysmal nocturnal, etc.
- main site of pain, character of pain, radiation, reliving and aggravating factors, nay medicinal history for pain [nitrates]
- regular and irregular, duration and site of palpitation, cough, dyspnoea, any blood in coughing etc.
respiratory system examination —
- cough is very important, is it dry or wet productive, colour of it, dour of it, any history of allergy, medication, etc.
- it is also very important in diagnosis, quantity, colour, smell, consistency, any blood or pus, timing in day and night, etc.
- 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.
- 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.
- 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.
- mouth and pharynx, breath and smell, lips- colour and pigmentation
- action, pharynx movement, neck movement, lymph glands
- 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.
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.
- for normal resonance present or not, if not then what kind of resonance is it-
- hyper resonance,
- superficial or deep dullness, etc.
- used for heart sound,
- auscultation for beats,
- breath sounds, and vocal resonance, etc.
- is there any problem with movement or shape of spine,or any deformity, etc.
- abdomen size, is any distention,
- flanks, intestinal movement,
- peristalsis, pubic hair, is any sign for hernia, etc.
- is any tenderness, rigidity, hyperesthesia, liver, gall bladder, kidney and spleen enlargement, urinary bladder, etc
- masses, liver, spleen bladder, size enlargement, etc
- bowel movement sound, aortic bruit, etc.
- 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.