How to take good medical history & examination

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.
systemic examination

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.
physical examination  —

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.