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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