GENERAL OUTLINE OF CASE TAKING
- History taking
differential diagnosis and provisional diagnosis
- physical examination
confirms history taking
- special diagnosis
- clinical diagnosis
- treatment ( medical and surgical )
- treatment progress and follow up
- termination
main objective is to funnel ( narrow ) down the differential diagnosis
HISTORY TAKING
A. Patient particulars
- Date of admission , respondent name
1. Name
- to know the patient
-identification
-rappot building
2. Age
- congenital anamolies - cystic hygroma , cleft lip, cleft palate , sacro-coccygeal teratoma , phimosis
- infants - wilms tumor , acute arthiritis , acute osteomyelitis
- teen girls -appendicitis
- old age -prostate enlargement ,osteoarthirits
3.sex
disease affecting sexual organs
predilection
females - thyroid disorder , visveroptosis , movable kidney , cystitis
male - ca stomach , lungs , kidneys
only male - hemophilia ( transmitted through females )
4. Religion
ca of penis -less common in jews and muslim
phimosis , subprepucial infarction - seen not at all in above mentioned religions
intusucception can be seen in after month of ramjan ( prolonged fasting )
5.Social Status
high social status - acute appendicitis, obesity , non communicable disease
low social status - Tuberculosis ,malnutrition , communicable disease
6.Occupation
long standing occupation - varicose veins
dye factories - urinary bladder ca
chimney - scrotal ca
Student's elbow , House maids knee , tennis elbow , carpel tunnel syndrome
7. Address
filariasis
Malaria
bilharziasis - egypt , sleeping sickness - africa
B. Chief Complaints ( What brought you here ? )
- Chronoligical order > Severity
- ask duration
- if were prefectly well before the chief complaints
C. History of present illness
- elaboration of cheif complaints
-recorded in patient's own language
- certain common
onset , progession( fluctuation ) , character , treatment recieved , aggravating and relieving factors , associated symptoms
- Leading questions should be used as less as possible
-pertinent negative history
- systematic review
- CVS - Palpitaion, Orthopnea , PND , Swelling of limbs , chest pain , SOB
- Respi - Cough , Chest pain , SOB, Sputum , hemoptysis , night sweats , fever,
- GI - Anorexia ,vomiting, Weight loss , bowel habits , hemetemesis ,dysphagia , malena
- Neuro -altered sensorium , LOC , epilepsy , sleep disturbances , any positive or negative sensory symptoms , movement disorder , cranial nerve functions
- Urinary - Urinary symptoms (urgency , frequency ,nocturia , dysuria , PMD . incontinence ,hesitancy ) , urine characteristics , back ache
any longterm illness
D. Past history
-all previous ilness , recorded in chronological order
E. Personal History
- diet history
- substance abuse history
-marital status
-menstual history in women
- Partum
F. Family History
- genetic disease hemophilia
-certain NCDs DM , HTN , PUD
-infectious - TB
-fissure-in-ano ,piles
similar ilness ,untimely demise in the family
G.History of immunisation
-diptheria , tetanus ,whooping cough, poliomyelitis , Small pox , tuberculosis
H. History of allergy
- allergic to any known substance
-allergic to any given medicine
H.