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History And Examination
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  • 1. History and Examination It is important to take a plan for the patient’s care based on: SOAP technique S= Subjective i.e. History O= Objective i.e. Examination A= Assessment (Impression) P= Plan HISTORY: 1. Personal Data:Name...Age...Sex...Nationality...Marital Status(S, M, D, W)...Occupation…Religion…Address 2. Chief Complaint: Main Complaint (s)………………………………Duration 3. History of Present Complaint (s): Patient admitted through OPD/ER….. Analysis of chief complaints… PAIN (Onset, Site, Severity, Character, Nature, Radiation or Referred or Radicular, Relieving and Aggravating Factors) Relation of these complaints to the SYSTEM (s) affected NOTE: At the end of this session you should know the DIFFERENTIAL DIAGNOSIS or at least the working diagnosis. 4. Systemic Inquiry: All systems should be inquired….Revise Questions of each system 5. Past History: Medical……… ...Surgical……… Blood Transfusion 6. Family History: of any familial diseases which run in families 7. Obs & Gyn History: in female 8. Drug History: Name of drugs………Frequency….Dose……...Allergic reactions to certain medicine 9. Social History: Marital and living conditions…level of education…Habits…Smoking or drinking or drug abuse…Travel Attitudes. 1428 ،‫اﻟﺜﻼﺛﺎء، 51 ﺷﻌﺒﺎن‬ 1 PDF created with pdfFactory Pro trial version www.pdffactory.com
  • 2. EXAMINATION: GENERAL: Brain Functions (Consciousness, Orientation, and Alertness)….Eyes (Pallor, Jaundice)….Nose…Mouth and Floor of the mouth (Pallor, Jaundice and Cyanosis in lips)….Neck (Masses, Lymph Nodes)……Axillae (Lymph Nodes)…..Hand Examination…..Lower Limb Edema…Vital Signs…Height and Weight (Body Mass Index”BMI”=Weight in Kg / (Height in Meters)2. SYSTEMIC: Examine all systems…. CVS…. RESP. SYSTEM….GIT….UG….CNS….MSK LOCAL: Inspection………….Palpation…………….Percussion………………………..Ausculta tion ASSESSMENT / IMPRESSION: What you think of the problem PLAN: Action to be taken to treat the patient (Management: i.e. Investigations and Treatment) 1425 ،‫اﻻرﺑﻌﺎء، 02 ﺟﻤﺎدى اﻷوﻟﻰ‬ 2 PDF created with pdfFactory Pro trial version www.pdffactory.com

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