Method of history taking

Method of history taking

Accurate diagnosis rests firmly upon the foundation of a
• thoughtful and inclusive history and a
• competently performed physical examination.

Personal ID

• Name, address, phone, nearest of kin.
• Age, sex, occupation, marital status.
• Date of Entry and Hospital Number.
• Source : usually the pt. but can be a family member, friend, letter of referral or the medical record.
• Reliability of Informant: varies according to the pt.’s memory, trust, & mood.
• Previous Entries：
– Dates, diagnoses, treatment, significant complications.
• Chief complaints (CC）：
– Presenting complaints .
– Written as severity or duration.

Present Illness（ PI）

A： The immediate history that brought the patient to the hospital.
B： Background history of disease leading to the immediate history
C: Includes patients thoughts & feelings about the illness.
D： Significant positive and negative data that might give clues useful in differential diagnosis.
E: May include medications, allergies, habits of smoking & alcohol.

Past Medical History

A： Hospitalization
B： Major Medical Illness; DM, HTN, Asthma
C： Trauma
D： Surgery/Operations; Dates, indication, types of operation
E： Childhood diseases/ illness- measles, mumps, chicken pox

Family History

A： Father; age & health, age & cause of death, medical illness eg HTN, CAD, CVA, suicide, mental illness etc.
B： Mother
C： Each sibling
D： History of disease in which heredity or contact may play a role.
E： Record a family tree

Marital History

A： Age and health of spouse； year married
B： Ages and health of children
C： Previous marriages (if any)

Menstrual History

• Age of menarche
• Date last menstrual period.
• Amount, frequency & duration of menstrual flow. Social History
• A： Serial residences (change of home/places)
• B： Education
• C： Employment
• D： Military service

Personal History

• A： Appetite
• B： Use alcohol , tobacco， coffee， tea，
• C： Sexual habits (e.g. loss of libido, premature ejaculation, dysparenia)
• Allergies：
• Hay fever (allergic rhinitis)， asthma ， hives (rashes)， food,drugs.
• Drug Use.
– A： Medicines (why, dose, regular/irregular)
– B： Drug abuse (oral? Iv? Needle sharing?)
• Weight：
– A： Highest
– B： Average
– C： Present

System History

Physical Examination-general
• 1. Vital Signs
– Blood pressure： Pulse rate：
– Temperature： Respiratory rate：
– Height： Weight：
– General appearance：
2.Mental status: orientation to time, place and person. Judgement (e.g. what will you do if you find a stamped envelope with address)
3.Neck shape， trachea， thyroid， blood vessels.
4.Breasts： symmetry， nipples， masses， tenderness.
5.Chest： skin， thorax（ shape， symmetry）
– ⑴Lungs： fremitus (ask pt. to say 99)
– Fremitus is a vibration transmitted through the body. In common medical usage, it usually refers to assessment of the lungs by either the vibration intensity felt on the chest wall (tactile fremitus) and/or heard by a stethoscope on the chest wall with certain spoken words (vocal fremitus)
– Increased fremitus (the consolidation e.g. pneumonia) than in a gaseous medium (aerated lung).
– Decreased fremitus in a pleural effusion or pneumothorax.
– resonance，
– breath sounds
5.Chest： skin， thorax（ shape， symmetry）
– ⑵Heart：
• Inspection： jugular venous pulsations
• The patient is positioned under 45°, and the filling level of the jugular vein determined. Visualize the internal jugular vein when looking for the pulsation. In healthy people, the filling level of the jugular vein should be less than 3 centimeters vertical height above the sternal angle
5.Chest： skin， thorax（ shape， symmetry）
• PMI (point of maximal impulse: usually left 5th intercostal space)
• Palpation： locate PMI， thrill
• Percussion： heart size
• Auscultation： Rate， rhythm, heart sounds (S1 and S2), murmurs.
6.Abdomen： contour， skin， hair and scars.
⑴intestinal activity
⑵rigidity and tenderness.
⑶Percussion for dullness.
⑷organs and masses
⑸shifting dullness
⑹collateral circulation

Back

• Curvatures， symmetry， mobility
• Tenderness over spine
• Pelvis
• Kidneys（ costovertebral angle tenderness）
• Rectum：
• Genitals：
• Pelvis：
• Extremities：
Cranial Nerves
• Cerebellum (walking gait: tendency to fall)
• Sensory function (equal sensation on both sides or not)
• Motor function (power of upper and lower limbs)
• Reflexes： Right and left
– Biceps
– Triceps
– Patellar
– Ankle
– Cremasteric (in male only): gentle stroking on medial aspect of thigh causes elevation of testes
– Abdominal
– Plantar (Babinski’sign). Downward and flexion of toes is normal. Upward and fanning of toes means upper motor neuron damage e.g. Trauma to head after bike accident or fall from tree or stroke.

Basic Laboratory Data

1.Hematology： WBC， RBC， Hematocrit， platelet
2.Urinalysis
3.Stool Guaiac (occult blood in stool)
4.Sputum Smear
5.Electrocardiogram
6.Purified Protein Derivative（ PPD): Tuberculosis
7.Chest X-ray

Summary

• Brief but essential summary of

⑴history
⑵physical examination
Formulation of Diagnoses.
• Problems and Plans
• Define and solve each diagnosis and problem individually.
• 1. Diagnoses
– ⑴ Analysis
– ⑵Plans： Diagnostic tests
– Therapeutic measures
• 2.Problems
– ⑴Analysis
– ⑵Plans： Diagnostic Therapeutic

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