Clinical Examination: Steps Of
Taking Patient History (Medicine)
When a patient admitted in
hospital,after admission procedure, the patient history must be taken by the
doctors.The case notes or records are the written records of a patient's
medical condition.
They include your initial
findings,proposed investigation and plan of management together with
the information about the patient's progress.When I entered ward classes
of 3rd year of MBBS course,the first thing my professor asked me to know
is the steps of taking patient history.So let me start…
The Steps of History
Taking/Documenting the Findings
1.First
of all,greet the patient.
2.Introduce
yourself.It may be appropriate to shake hand with the patient.(if you
are a student and studying at undeveloped country Better don't do
this..from my own experience).
3:Demographic
Details(Particulars of the patient)
Always record
-Patient's name
- address
-date of birth
-age
-any
national health identification number
-source of referral and the
general practitioner's name and address
-source of history
-date and time of examination
4:Presenting
Complaint/Chief Complaint
-state the major problem
in one or two of the patient's own word followed by the duration of the each.
-do not use medical term.
5:History
of Presenting Complaint/Present Illness
-describe the onset
,nature ad course of each symptom.Paraphrase the patient account and condense i
if necessary.Omit irrelevant details.Include other part of the history if
relevant such as smoking or family history in disorders with a possible genetic
trait like diabetes.
6:Past
History/History of pass illness
-tabulate them in
chronological order.Include important negatives things like previous disorder
.Because past history of disorder leads to new disorder.
7:Drug
History
-Tabulate these and
include any allergies particularly to drugs.Record any previous adverse drug
reaction as well
8:Family
History
-Record the age and
current health or the cause and the ages of the death of the patient's parents
siblings etc.
9:Social History
-occupation
-marital status
-living environment
-smoking
-alcohol
-illicit drug use
-social support
10:Systemic Enquiry
document positive responses that do not feature in the history of
presenting complaint
-cvs
-respiratory system
-git
-endocrine system and
etc
11:General on Examination
-physical appearance
-mental state
-undernourished ,obese
-abnormal smell like uraemia
-height,weight
-skin like cyanosis
,pallor,jaundice,rashes
-breast size,mass
-hand finger clubbing ,nail color
-lymph
node,character,site
12:Cardiovascular System
-pulse
-rate
-rhythm
-character,volume
-blood pressure
-jugular venous pressure,height
character
-ankle oedema
-apex beat
-hearth sound, murmur
-peripheral pulse
-bruits
13:Respiratory System
-any chest wall
deformity
-trachea central or deviated
-sign of hyperinflation
-expansion and its symmetry
-percussion note ,site
-breath sound
-vocal resonance
14:Abdominal System
Mouth
-any abnormality
Abdomen
-scars and site
-shape,distended or scaphoid
-hernial orifices
-tenderness ad guarding and site of
this
-masses and description
-enlargement of liver
,kidney and spleen
-ascites if present
-bowel sound
-rectal examination
-in women -vaginal examination
-in men -external genitalia
15:Central Nervous System :
In older patient record
the abbreviated mental test(AMT) score in impaired consciousness ,head
injury or record the Glasgow Coma Scale
Abnormal speech
tabulate the remaining
examination
-pupil equal and react to light and
accommodation
-upper limb
-lower limb
-knee
etc
-Cranial nerves record abnormalities
only
-fundoscopy
16:Musculoskeletal System :
-Gait if abnormal
-Muscle or soft tissue changes
-swelling ,color
,heat,tenderness
-deformities in the
bones of joints
-limited of ranges of
movement
Clinical Diagnosis or
Impression
Record your conclusion and the most
likely diagnoses in order of probability
In patient with multiple pathology
make a problem list s the key issues are seen immediately
17:Plan
-list the investigation
required.When a result is ready available record it.
-record any immediate management
instigated
-if uncertain about
an investigation or treatment ,precede with a ‘?’ and discuss with a more
senior member of staff.
18:Information Given
Document what you have
told the patient any any other family members.It is also important to document
any diagnosis that you have not discussed.
19:Progress Notes
Finally,follow the same structures with these additions
#Changes in the patient symptoms
#Examination findings
#Result of new investigation
#Clinical impression of the patient's
progress
#Plans for further management
,particularly drug changes.
Make progress
notes regularly depending on the speed of the changes in the
patient's condition several times a day,but in stable condition daily or
alternate days
Date ,time and sign all entries.
Record any unexpected change in the
patient's condition as well as a routine progress notes.
By lakdhes
Reference: Macleod’s Clinical Examination
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