Clinical History Taking and Examination Format

GUIDE - HOW TO TAKE GOOD AND COMPLETE MEDICAL HISTORY OF PATIENT IN MEDICAL MBBS THIRD YEAR, FOURTH YEAR AND INTERNSHIP

Clinical history taking is an art of extracting out the smallest of information from the patient and reaching to a possible diagnosis. For Medical(MBBS) students and Interns, it is a vital thing to learn, understand and interpret in order to become a professional Doctor. Without it, you are definitely not going to pass in the practical exams indeed. Here we present the basic layout of taking history which can be used to avoid missing important points. If we still missed anything, don't forget to point it out. 
NOTE: Always remember standing on RIGHT SIDE of patient while taking the history.


PARTICULARS OF PATIENT

1. Name
2. Age
3. Sex
4. Religion
5. Occupation
6. Address
7. D.O.A (Date Of Admission)
8. D.O.E (Date Of Examination)

HISTORY PROPER

1. C/C (Chief Complaints)
2. HOPI (History Of Present Illness)
3. Past history
4. Personal history
5. Family history
6. Rx history (Treatment history)
7. Psychological history
8. Menstrual/Obs. history in females


PHYSICAL EXAMINATION

I. General survey

1. Level of consciousness- whether patient is alert, co-operative and oriented to time and space
2. Apparent age- Patient may look younger in Down's syndrome, Thallasaemia, Pituitary dwarf or patient may look older than his/her age in Progeria (Extremely rare genetic disorder in which aging occurs at very early age) or Precocious puberty (Development at earlier age than usual)
3. Decubitus (Position of patient)
4. Built- Average/Dwarf/Tall strature
5. Nutrition- Average/Underweight/Obese (try to get bmi)
6. Facial appearance
7. Pallor
8. Icterus
9. Cyanosis
10. Neck vein (J.V.P, J.V engorgement, J.V pulse)
11. Neck artery (Carotid arteries)
12. L.N (Lymph nodes all over body)
13. Thyroid gland
14. Clubbing
15. Koilonychia (Spoon nails) - Hypochromic anaemia in Iron deficiency anaemia
16. Pulse- Rate, Rhythm, Volume, Condition of arterial wall, Comparison b/w 2 radial pulses, Radiofemoral delay, any special character, Other peripheral pulses
17. Respiration- Rate, Rhythm, Depth, Breathing pattern)
18. Temperature- Oral temperature
19. B.P (Blood pressure in mm Hg)
20. Oedema
21. Skin, Hairs, Nails
22. Height and Weight
23. Any obvious deformity of skull, spine, limbs, swelling of abdomen
24. General- any acute distress present or not
25. Handedness (Right/Left) with level of intelligence (Average/Low/High)

II. Systemic Examination 

1. CVS (Cardiovascular system)
2. Respiratory system
3. GIT (Gastrointestinal tract) system
4. Nervous system
5. Genitourinary system
6. Lymphoreticular system
7. Locomotor system (Optional)


SUMMARY OF CASE

It should be in few lines, explaining the general information of patient and then key points. Always reach 5 points :-
1. C/C of patient
2. Organ system affected
2. Onset of symptoms (Acute/Chronic)
3. Aetiology (Infectious, inflammatory, traumatic, genetic, etc.)
4. Possible diagnosis
So, it could be like- Patient named xxx aged xx years presented on xx/xx/xx date with such and such complaints. xx appeared to be affected and on examination, xx was revealed which was acute/chronic in onset and having xx possible aetiology. The provisional diagnosis appears to be xx.

PROVISIONAL DIAGNOSIS

The most possible diagnosis you can make out of case.

DIFFERENTIAL DIAGNOSIS

Make a list of possible diagnosis and rule out individually to reach to the exact diagnosis.


RELEVANT INVESTIGATION (OPTIONAL)

Certain investigations like xray, usg, ct, etc can be asked for more detailed information.

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