History taking and physical examination

[IsseGole]

History taking and physical examination

History taking:

1)   Personal history:
Name      Occupation   
Age      Marital status   
Sex      Special habits   
Residence         
2)   Complaint:

3)   History of Present illness: Analysis of the complaint

Pain
SOCRATES
Site:             Onset:
Nature:              Duration: 
Progression:              End:
Releived by:          Aggravated by:
Radiation:           Cause:

Swelling   
Site:             Duration:
First symptom:          Others:
Progression:         Persistence: 
Multiplicity:          Cause:

4)   Symptoms of the abnormal system and other systems:

Respiratory System:
Cough:             Sputum:
Hemoptysis:          Dyspnoea:
Chest pain:


GenitoUrinary Tract:    
Urine: amount/color/content:
Obstr. Sympt.:
Irritative sympt.: 
Uremic manifestations:
Thirst:                                                 Oedema:
Suprapubic mass:                           
Dyspareunia:                                     Imptence:
Menarche:                                         Menopause:
Menstruation:                                          Dysmenorrhoea:       
Pregnancies:                                            Breast symptoms:


GastroIntestinal Tract:    
Dysphagia:                                        Taste:
Haematemesis:                                   Appetite:
Vomiting:                                            Heartburn:   
Idigestion:                                           Abd. Distension:
Stool charecters:
Hematochezia:                                    Flatulence:
Jaundice:                                             Oedema:
Bleeding tendency:


CardioVascular System:    
Palpitation:                                          Headache:
Ankle swelling:                                   Cardiac pain:
Orthopnea:                                           PND:

Central Nervous System:    
Nervousness:                                       Tremor:                                           
Faintings:                                             Special senses:
Paralysis:                                              Paraesthesia:
Headache:                                             Behaviour chages:

MusculoSkeletal System:
Joint Pain:                                           Muscle Pain:
Any Diformity:                                   Motion:
Weakness:                                          Joint swellings:
Peripheral Vascular Symptoms:
Claudications:                                          Limb pain:


5)   Previous history:
Operations:      Accidents:   
Illnesses:   DM, RF, TB, Asthma, HT, Allergies:    Drugs:    
STDs:                       Immunization:
   
6)   Social and Family history:
Hereditary diseases:       Cause of death of relatives:    
Consanguinity:                       Hazards exp.:   
Socioec. status:                       Others:    

Clinical examinations:

1)   General appearance:
Mental status   
Posture      Weight   
Face      Others   

2)   Vital signs:
Temperature      Pulse   
Resp. rate:       Blood pressure:   

3)   Systemic examinations: inspection:
Head: Skull      Lips   
Eyes                      Tongue   

Neck   
Chest   
Upper limb   
Back   
Lower limb   
Abdomen   

4)   The Clinical examinations: :
Palpation: on the affected body system.

Percussion: on the chest and abdomen if they are affected.    

Auscultation: Cardiac mostly, also abdomen and others.



Diagnosis:

1.   Investigations  and results:





2.   Differential diagnoses:





3.   Final diagnoses:




4.   Treatment and Follow up:






By: Issa Bashir Mohamed
University of Science and Technology / Sana'a / Yemen
1/12/2005



This was a special history sheet for surgical patients in the first place, and then I added examination in order to remember it and write comments for easy presentation.
Tha blanks are supposed to fit by positive and negative signs, and to help in recording and preserving the cases taken by the student in his long way studying in medicine.
The references are Browse's clinical examination, MacLoed's clinical examination, and egyptian surgical examination book.
Hope you the best.
Ciise Dheere