Medical History Taking : Clinical Features (Chief Complaints) & Suggestive Involved System
A. General
1. Fever
- Duration
- Onset (Sudden/Insidious or Gradual)
- Severity (High/Moderate/Low Grade)
- Diurnal Variation
- Type
- Aggravating & Relieving Factors
- Associated Symptoms (Sweating, Chills, Rigor, Myalgia)
2. Pain
- Duration
- Onset (Sudden/Insidious or Gradual)
- Severity (High/Moderate/Low Grade)
- Progression
- Site
- Radiation
- Character (Stabbing, Picking, Aching, Throbbing, Shooting, Colic, Twisting)
- Type (Superficial, Deep, Segmental, Psychogenic)
- Aggravating & Relieving Factors
- Associated Symptoms
3. Edema
- Duration
- Onset (Sudden/Insidious or Gradual)
- Severity
- Where did it appear first?
- Site
- Unilateral or Bilateral
- Progression
- Painful or Painless
- Diurnal Variation
- Urine Output
- Aggravating & Relieving Factors
- Associated Symptoms
B. Suggestive of cardio-respiratory disease
1. Cough
- Duration (Acue <3 Week, Chronic > 3 Week)
- Onset (Sudden/Insidious or Gradual)
- Severity (Prolonged/Short/Paroxysmal)
- Progressive
- Type (Dry without expectoration, Wet with expectoration)
- Character (Whooping: Pertussis, Croupy: LTB, Brassy: Ca Larynx)
- Diurnal Variation
- Seasonal Variation
- Postural Variation
- Precipitating Factors (e.g. dust, pollen, fume, cold air)
- Associated Symptoms (Chest pain, hemoptysis, breathlessness)
- Sputum Analysis
Sputum Analysis
- Amount (Profuse/Scanty)
- Character (Serous, Mucoid, Purulent, Mucopurulent)
- Color
- Odour
- Taste (Salty: Alveolar Cell Ca)
- Blood tinged
- Appearance (Rusty, Streaky, Frothy)
- Frequency
2. Breathlessness
- Onset (Sudden/Insidious)
- Severity (At its height)
- Progressive or not?
- Duration
- Exertional or non exertional
- If Exertional, Grade (NYHA Classification)
NYHA Classification
- No limitation of activity with normal physical work
- Breathlessness on ordinary activity but normal at rest
- Limitation of activity on mild physical activity
- Limitation of activity at rest, restricting person to bed.
- Diurnal Variation (Early night: Cardiac asthma, Early morning: Bronchil asthma)
- Seasonal Variation
- Postural Variation (Orthopnoea, Platypnoea, Trepoponea)
- Associated Symptoms (Wheeze, PND Paroxysmal nocturnal dyspnea, Cough, Pain chest, Shock, Fever, Angina Pain, Bluish discoloration of finger/nails/toes)
- Aggravating Factors (Smoking, Posture)
- Relieving Factors (Drug, Rest)
3. Palpitations
- Duration
- Onset
- Intermittent / Sustained
- Regular / Irregular
- Progess
- Associated Symptoms
4. Chest Pain
- Pleuritic chest pain is superficial, well localized, & worsen on deep breathing/coughing/sneezing.
- Anginal chest pain is deep seated & poorly localized, & worsen on exertion.
5. Fainting Attacks (Syncope)
- Duration
- Frequency
- Position at onset
C. Suggestive of GIT disease
1. Vomiting
- Duration
- Frequency / 24 hours
- Associated nausea, abdominal pain
- Content
- Colour
- Projectile/Non projectile
- Blood in vomitus
- Associated symptoms
2. Loose motion
- Duration
- Frequency / 24 hours
- Type (Watery/Rice water/Semi solid)
- Content (Worms, undigested food particles)
- Colour
- Presence of blood or mucus
- Associated symptoms
3. Abdominal pain
4. Loss of appetite
- Duration
- It is for any particular food?
- Loss of weight
- Associated symptoms
5. Bleeding per rectum
- Duration
- Amount
- Colour
- Malaena / Haematoctezia
6. Jaundice
- Duration
- How it was noticed?
- H/o high coloured urine
- H/o clay coloured stools
- H/o pruritis
- H/o drug intake
- Associated symptoms
D. Suggestive of UTI
- Frequency of micturition
- Pyuria
- Hematuria
- Burning micturition
- Flank or renal angle pain
E. Suggestive of CNS
1. Power loss
- Duration
- Onset
- Affected limbs
- Muscle group affected
- Details of events
- Progress
- H/o stiffness
- H/o thinning of affected limbs
2. Sensory complaints (Tingling, numbness, pins & needles sensation, burning sensation of palms & soles etc.)
- Duration
- Onset
- Progress (Where it began & how it progressed to other parts)
- Appreciation of hot/cold (e.g. bathing)
- Appreciation of touch (e.g. clothes on body)
- Associated symptoms
3. Involuntary movements (Tremors, chorea, athetosis etc.)
- Duration
- Onset
- Parts of body involved
- Aggravating factors
- Relieving factors
- Associated symptoms
4. Bladder
- Retention of urine
- Precipitancy
- Hesitancy
- Incontinence
- Automatic micturition
- Autonomous micturition
Enquire about onset, duration, associated symptoms etc.
5. Bowel incontinence
6. History of cranial nerve dysfunction
e.g.
- Visual disturbance
- Diplopia
- Dysphagia etc.
7. History of loss of consciousness
- Detail
8. History of seizures or fits
- Duration
- Frequency
- What patient was doing at the time of onset?
- Focal / General
- Tonic / Clonic
- H/o tongue bite
- H/o uprolling eyes
- H/o frothing
- H/o incontinence
- H/o any injury
- H/o any sensory disturbances
- H/o precipitating factors (Alcohol, menses etc.)
- H/o postictal palsy / neurological deficits
9. History of difficulty in speaking or reading
10. History of raised ICP
- Headaches
- Blurring of vision
- Vomiting
11. Tinnitus, Giddiness, Blackouts, Syncope, Drop attacks
- Duration
- Frequency
- Associated symptoms
12. History of
- Trauma
- Fever
- Ear discharge
- Bleeding tendencies
- Exposure to environmental toxins
- Recent vaccination
F. Consumption of poison
- Time, Date
- Name, nature, quantity of poison consumed
- Symptoms developed after consumption of poison
- Time elapsed between consumption of poison & reaching
- Was stomach was given?
- Purpose of consumption
- Any other
G. Joint pain
- Duration
- Onset
- Joint involved in chronological order
- H/o morning stiffness
- H/o joint swelling
- H/o restricted movements
- H/o joint deformity
- Associated symptoms
