Most history taking follows the below format

  1. Details of the patient
  2. History
  3. Physical examination
  4. Summary
  5. Diagnosis
  6. Differential diagnosis
  7. Investigations
  8. Management
  9. History of presenting complaints

1) Details of the patient

  1. Name
  2. Sex
  3. Age
  4. Occupation
  5. Address
  6. Accompanying person and the relation

2) History

  1. Chief presenting complaints
  2. Past medical history
  3. Family history
  4. Treatment history
  5. Psychological history
  6. Obstetric history in females

3) Physical examination

  • Look around the room to see if any accessories/ instruments like crutches/ wheelchairs/ glasses/ inhalers
  • Once the child is seated, ask if you could expose the upper body.
  • For lover body, you may need to ask permission from the examiner also

4) General examination

  • Level of consciousness- Alert/ Oriented/ cooperative
  • Decubitus (position in bed)
  • Gait
  • Built- Average/ small or large for age
  • Nutrition- Average/ undernutrition
  • Anemia- pallor present/ pink ( pale mouth/ nails)
  • Cyanosis- central and peripheral
  • Jaundice- present/ absent
  • Neck veins/ Carotid artery pulsation
  • Respiration effort- rate, rhythm, pattern, depth, laboured or not
  • Scars on the body- Chest/ neck/ abdomen
  • Oedema- Present/ absent
  • Any obvious deformity

Look into notes (If available) for

  • Temperature
  • Blood pressure
  • Skin, hair, nails
  • Height, weight

Systemic examination

The following is the classification of systems in exams

  1. Cardiovascular system
  2. Central nervous system
  3. Respiratory system
  4. GastroIntestinal system
  5. Genitourinary system
  6. Lymphoreticular system
  7. Musculoskeletal system

Look at further section for details of each system

History taking is an art and has to be practised each time you see a patient.

Read other articles for further information.

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