History taking scheme
Most history taking follows the below format
- Details of the patient
- History
- Physical examination
- Summary
- Diagnosis
- Differential diagnosis
- Investigations
- Management
- History of presenting complaints
1) Details of the patient
- Name
- Sex
- Age
- Occupation
- Address
- Accompanying person and the relation
2) History
- Chief presenting complaints
- Past medical history
- Family history
- Treatment history
- Psychological history
- 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
- Cardiovascular system
- Central nervous system
- Respiratory system
- GastroIntestinal system
- Genitourinary system
- Lymphoreticular system
- 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.