History Taking

History Taking

General Pain

  • Location
  • Since when
  • Onset
  • Duration
  • Type
  • Character
  • Radiation
  • Progression
  • Aggravating / Relieving factor
  • Postural variation
  • Diurnal variation
  • Seasonal variation

Joint Pain

  • Since when
  • Onset
  • Duration
  • Type
  • Character
  • Which joint
  • Any swelling, redness, wound
  • Restriction of movement
  • Aggravating / relieving factor
  • Medication taken
  • Postural variation
  • Diurnal variation
History of:
  • Exercise
  • Work
  • Fall
  • Fever

Weakness

  • Since when
  • Generalised or not
  • Whether it is due to diet
  • Whether it is due to fever

Fever

  • Since when
  • Onset
  • Grade: High/Low
  • Continuous/Intermittent
  • Spikes per day if intermittent
  • Worse in the morning/evening/night
  • Associated with chills/Rigors
  • Progression
  • Diurnal variation
  • Seasonal variation
  • Medication taken

Rashes

  • Since when
  • Which part of body
  • Initial size
  • Current size
  • What colour
  • Progression 
  • Presence of itchiness
  • Generalised / Localised 
  • Symmetrical / Asymmetrical 

Vomiting

  • Since when
  • Onset
  • How many times
  • Volume/Quantity
  • Colour
  • Solid/Watery
  • Composition (food particles)
  • Projectile/Non projectile
  • Relieving/ Aggravating factor
  • Progression
  • Diurnal variation
  • Postural variation
  • Seasonal variation

Cough

  • Since when
  • Onset
  • How many times per day
  • Productive/Non productive
  • Character: Persistent/Intermittent
  • Associated with blood
  • Diurnal variation
  • Seasonal variation
  • Postural variation
  • Aggravating/Relieving factor
  • Medication taken

Sputum

  • Colour
  • Volume
  • Consistency: mucoid
  • Foul smelling
  • Blood stain

Breathlessness / Dyspnoea

  • Since when
  • Onset
  • Duration
  • Diurnal variation
  • Postural variation
  • Seasonal variation
History of:
  • Cough
  • Fever

Wheezing

  • Since when
  • Onset
  • Character: Persistent/Intermittent
  • Diurnal/Nocturnal variation
  • Postural variation

Chest Pain

  • Since when
  • Onset
  • Location
  • Type of pain: Throbbing/Burning
  • Character: Persistent/Intermittent
  • Radiation
  • Aggravating/Relieving factor
  • Postural variation
  • Progression

Abdominal Pain

  • Since when
  • Onset
  • How many times per day
  • Location
  • Type
  • Character
  • Radiation
  • Associated with food intake: Before/After
  • Postural variation
  • Diurnal/Nocturnal variation
  • Aggravating/Relieving factor
  • Medication taken

Diarrhoea / Loose Stool

  • Since when
  • Onset
  • Duration (how many days)
  • Number of episodes / frequency
  • Colour
  • Volume
  • Blood in stool
  • Consistency
History of:
  • Vomiting

Difficulty / Pain in Passing Urine

  • Since when
  • Onset
  • Burning sensation
  • Frequency
  • Amount / Urine output
  • Colour
  • Presence of blood
  • Changes in smell
  • Urgency
  • Nocturia
  • Loin / Back pain
  • Vaginal / Urethral discharge
  • Dyspareunia 
  • Swelling of scrotum
  • Anogenital ulcer
History of:
  • Fever: UTI
  • Increased frequency: Elderly, BPH

Dizziness

  • Since when
  • Onset: Acute /Chronic
  • Duration
    • Seconds:
      • Benign paroxysmal positional vertigo (BPPV)
      • Orthostatic hypotension
    • Minutes:
      • Transient ischemic attacks of the posterior circulation
      • Migraine 
    • Hours:
      • Vestibular migraine 
      • Ménière's disease
  • Unilateral / Bilateral
  • Progression
  • Whether it is first attack
  • Aggravating factor
  • Accompanying symptoms
    • Peripheral causes
      • Unilateral hearing loss
      • Aural symptoms (ear pain, pressure, fullness)
    • Central causes - brainstem or cerebellar lesion
      • Double vision
      • Numbness
      • Limb ataxia

Seizures


  • Since when
  • How many episode
  • Duration of each episode
  • Duration between each episode
  • Manifestation (upright eyes, frothing mouth, jerky movement)
  • What the patient do before seizure
  • Concious or not
  • Postictal drowsiness

History of:

  • Previous seizure
  • Birth asphyxia
  • CNS problem

Comments

Post a Comment

Popular posts from this blog

Lumbar Puncture Procedure

Lumbar Puncture Procedure Indication Diagnostic Meningitis Therapeutic Administration of drugs Decrease intracranial pressure Guillain – Barré syndrome Contraindication Increased ICP Patients under anticoagulant therapy Procedure If patient is under anticoagulant therapy Heparin Stop the drug 4 days prior to the procedure Aspirin Stop the drug 7 days prior to the procedure Instruments Lumbar puncture needle 22 Gauge Anaesthesia Injection Lignocaine Sample collection 3 samples 10ml each sample Microbiology Histopathology If repeated procedure indicated After 5 days of the previous procedure Complication Brain stem herniation Post dural headache Due to decreased ICP Prevented by 1 hour lying down before getting up Prevented by administration of paracetamol, caffeine, blood (epidural patch) Bowel & bladder incontinence Nerve damage due to negative pressure Infection
Read more

Furqan - Nabi Isa Ibni Maryam

Image
An-Nisa' 4:171 O People of the Scripture, do not commit excess in your religion or say about Allah except the truth. The Messiah, Jesus, the son of Mary, was but a messenger of Allah and His word which He directed to Mary and a soul [created at a command] from Him. So believe in Allah and His messengers. And do not say, "Three"; desist - it is better for you. Indeed, Allah is but one God. Exalted is He above having a son. To Him belongs whatever is in the heavens and whatever is on the earth. And sufficient is Allah as Disposer of affairs. Wahai Ahli Kitab! Janganlah kamu melampaui batas dalam agamamu, dan janganlah kamu mengatakan terhadap Allah kecuali yang benar. Sungguh, Al-Masih Isa putra Maryam itu, adalah utusan Allah dan (yang diciptakan dengan) kalimat-Nya yang disampaikan-Nya kepada Maryam, dan (dengan tiupan) roh dari-Nya. Maka berimanlah kepada Allah dan rasul-rasul-Nya dan janganlah kamu mengatakan, "(Tuhan itu) tiga,"Berhentilah (dari ucap...
Read more