History Taking

FuHaixiang
 Accurate diagnosis rests firmly
upon the foundation of a thoughtful
and inclusive history and a
compotently performed physical
examination.
 Personal ID
Name address phone nearest of
kin.Age sex rece occupation ma
rital status.
Date of Entry and Hospital Numbor
Source and Reliability of Iuformant
 Previous Entries
Dates diagnoses treatment signif
icant complications.
Chief complaints CC
Presenting complaints and duration.
 Present Illness PI
A The immediate history that brought the
patient to the hospital
B Background history of disease leeding
to the immediate history
C Significant positive and negative data
that might give clues useful in
differential diagnosis
 Family History

A Father
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
 Medical History
A Hospitalization
B Illness
C Trauma
D Operations
E Childhood diseases
 Social History
A Serial residences
B Education
C Employment
D Military service
 Habits
A Appetite
B Use alcohol coffee tea tobacco
C Sexual habits

Allergies
Hay fever asthma hives food skin
drugs
 Drug Use.
A Medicines
B Drug abuse
Weight
A Highest
B Average
C Present
 System History
Physical Examination-general
1.Vital Sighs
Blood pressure Pulse rate
Temperature Respiratory rate
Height Weight
General appearance
2.Mental status

3.Neck.shape trachea thyroid blood

vessels.

4.Breasts
symmetry nipples masses tendern
ess.
 5.Chest
skin thorax shape symmetry
Lungs fremitus resonance breath sounds
Heart
Inspection jugular venous pulsations point
PMI
Palpation locate PMI thrill
Percussion heart size
Auscultation Rate rhythm.Heart
sounds.murmurs.
 6.Abdomen contour skin hair
and scars.
intestinal activity
rigidity and tenderness.
Percussion for dullness.
organs and masses
shifting dullness
collateral circulation
 Back
Curvatures symmetry mobility
Tenderness over spine
Pelvis
Kidneys costovertebral angle
tenderness
 Rectum
Genitals
Pelvis
Extremities
Granial Nerves
Gait Cerebellum Sensory Associative
Functions Motor
 Reflexes Right left
Biceps
Triceps
Patellar
Ankle
Cremaster
Abdominal
Plantar
 Basic Laboratory Data
1.Hematology
WBC RBC Hematocrit platelet
2.Indexes
3.Urinalysis
4.Stool Guaiac
5.Sputum Smear
6.Electrocardiogram
7.Purified Protein Derivative PPD
8.Chest X-ray
 Summary
Brief but esseutial summary of
history
physical examination
contribution ancillary data
Formulation of Diagnoses.
Problems and Plans
Define and solve each diagnosis and problem
individually.
 1.Diagnoses
Analysis
Plans Diagnostic tests
Therapeutic measures
2.Problems
Analysis
Plans Diagnostic
Therapeutic