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History taking in chest and tb department


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This slideshare is to guide the beginners on "what to ask" while taking clinical history while in Respiratory medicine.

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History taking in chest and tb department

  1. 1. Dr. Prashant Shukla Junior Resident Dept of Pharmacology
  2. 2.  Name  Age  Sex  Chief Complaints:  Breathlessness: I. Since II. Worse on lying down/ standing/ working/ no effect at all III. Medications for the same IV. Diurnal variations V. Seasonal variations VI. Associated skin rash VII. Associated leg pain VIII. Associated chest pain IX. Associated pregnancy X. Associated OCP intake XI. Any known allergy XII. Ankle swelling XIII. Breathlessness on inspiration / expiration
  3. 3.  Cough i. Since ii. Severity iii. Type : • Serous • Mucoid • Mucopurulent • Rusty iv. Color v. Amount vi. Expectoration( productive/ non-productive) vii. Postural variations viii. Diurnal variation ix. Seasonal variation x. Blood in sputum xi. Associated chest pain xii. Sneezing xiii. Associated medications for the same xiv. Loss of appetite xv. Loss of weight xvi. Evening rise of temperature xvii. Haematemesis
  4. 4.  Chest pain I. Since II. Site/ side III. Radiation to IV. Associated perspiration V. Loss of consciousness VI. Sense of impending doom VII. Any medications/ hospitalization VIII. Exacerbating factors IX. Relieving factors X. Onset exertional/ progressive on rest/ sudden onset/ after meals XI. Nausea and vomiting XII. Trauma XIII. Palpitations XIV. Change with inspiration  Wheezing/ Stridor
  5. 5.  Fever I. Since II. Grade III. Diurnal variation IV. Medications for the same V. Urine discoloration VI. Associated with chills and rigor VII. Constipation/ Diarrhea VIII. Burning micturition  Epigastric pain I. Since II. Heartburn III. Relieved/ Exacerbated on food intake IV. Stool discoloration V. History of blood transfusions VI. History of vomiting a. Color b. Contents c. Projectile/ Non-projectile d. Presence of blood e. Duration after food intake
  6. 6.  Personal history I. Smoking bidis/ cigarettes/ hookah/ passive smoker II. Alcohol intake III. Abuse of afeem/ charas/ ganja/ cocaine/ bhang IV. Vegetarian / Non-vegetarian  Professional history  Medical history I. Similar problems II. Any reported allergy III. Bronchial asthma IV. Diabetes mellitus V. Myocardial infarction VI. Hypertension VII. Tuberculosis • Full treatment • Category • Treatment stopped since • Took medications for VIII. Any surgery IX. Any reported poisoning