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History of presenting illness  Chief complaint + SOCRATES

Severity:
- Subjective  scale of 1-10
- Objectivity  how it affects your daily lifestyle/work?

HISTORY:

Past medical history:


- Have u had anything similar before
- Ask associated symptoms of same system
- Ask chronic illness  diabetes, high cholesterol and hyper-tension?

Past surgical history:


- Have you ever been hospitalized
- Any surgery? What, why, when, complications, recovery?

Past trauma and accidental history:


- Any major trauma/accident

Past blood transfusion:


- Did you ever had any blood transfusion?

Past drug history:


- Are you taking medications for this problem
- Are you taking any other medication/prescribed medications
- Over the counter (OTC)
- Herbal
- Ask for patient compliancy

Past family history:


- Anyone has similar problem
- Anyone has chronic illness?
- Anyone has similar system associated diseases?
- Any genetic disease?
- Any history of recent death? How?

Vaccination history
- Are you up-to-date / vaccination card
- Did you have any recent vaccination

Allergies history
- Animals
- Food
- Environment/season

Past social history:


- Non-sensitive:
o Occupation, if he’s satisfied with his job, in debt , socio-economic status
o Diet and exercise  bowel habits
o Marital status
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- Sensitive: (confidential information, permission, why)
o Smoking? (what/shisha, how many, how long)
o Alcohol? (what type, how frequent, amount, how long)
o Recreational drug? (do u take any? Marijuana, weed)
o Sexual history? (orientation, no. of partners, last time u had sex, protective for both)

Travel history:
- Have you travelled recently
- Where, when (check for endemic areas)
- Have you had any contact with sick people (hajj)

Menstrual history:
- Age of menarche
- Last menstrual period and duration of it
- Regularity
- Flow (no. of tampons/pads)
- Associated symptoms

Obstetrical / gynaecologist history:


- Gravidity  no. of times pregnancy
- Parity  no. of times given birth
- Miscarriages/abortions

Cough:
- Site, radiation are removed
- Character dry, wet/productive:
- If wet: CABO: Color, Amount, Blood, and Odour.
- Associated symptoms: runny nose, burning, breathing problem

Fever:
- Site, radiation, severity are removed.
- Character  did u measure, if yes  how, highest value,
sweating, shivering
- Associated symptoms: headache, dizziness, loss of appetite, weight loss.
Constitutional symptom:
- Fever
- Fatigue
- Weight gain/loss
- Loss of apetite

Cardio-respiratory: swollen feet

Endocrine: diabetes polyphagia, polydipsia, polyuria


Thyroid  mood swings, heat intolerance

Vital signs, general exam, blood pressure, Lymph nodes  Approach patient from right side or from
the front

Heart rate report findings  Beats per minute, regular/irregular rhythm, normal volume
- Ideally, longer the better (60 seconds)
- Average time 60-100 bpm

Respiratory rate  Breaths per minute, regular rhythm, normal depth, accessory muscles
- Average 12-20 breaths per minute
- Observe chest movements

Temperature  Most important is oral


- Shake it till mercury goes below 35 and mercury is activated
- Highest  rectal, lowest  axillary
- Know the ranges
- Wait for 2 minutes
- Don’t let the guy bite it, mercury poisoning

BP:
- Cubital fossa at heart level.
- Brachial artery is medial to biceps tendon
- Palpatory method  taking the radial pulse
- 2-3 cm above cubital fossa
- Baseline pulse  is the pulse at which radial pulse disappears
- Next time add 20-30 mmHg when you are measuring with stethoscope
- First heart beat that you hear  systolic pressure
- The last heart beat you hear  diastolic pressure
- Record then thank

General exam:
- Conjuctiva  pallor
- Sclera  jaundice
- Lips  dehydration, central cyanosis
- Tongue  dehydration, central cyanosis, oral thrush, blood flow under tongue
- Firm pressure above medial malleolus by 3cm, press on tibia.

Upper LN:
- Clavicular LN are the only one that u examine from the front
- 2-3 fingers
- Right hand right side for support and vice versa
- Epitrochlear lymph nodes  above the medial epicondyle
- Size, location, consistency (firm, soft, hard), contour (rough, smooth edges), mobility,
tenderness (non-tender, tender/pain), pulsatile
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