The document provides guidance on taking patient history and summarizing clinical cases. It emphasizes listening to the patient's description of symptoms and events, only prompting when needed. Key details to document include the patient's identifying information, medical history, presenting symptoms and their duration, relevant risk factors and family history. The summary should concisely restate the important symptoms and chronology of the case without including verbatim details from the history.

2. The medical student analyses the details and prepares a summary The narration is split down into several steps It is then written down as a summary case sheet

3. Example: Diagnosis of migraine is made from history alone Otherwise history is supplemented by clinical examination You may also need investigations to confirm the diagnosis

4. Arriving at a diagnosis helps us in under standing the disease It helps in planning for necessary investigations Treating the disease for a possible cure or if not relief from symptoms

5. In taking a long cases as much as 10-20 minutes may be allotted Where as in a short case little or no history is taken In cases of medical emergencies you may not have time for history

6. Say “Hello” or “Good morning” or “Namaskaram” Also one must ask for permission for the interview What matters most is the rapport built up

7. You are from Parasalla, I am from idichakkaplamoodu Your father was an Abkari contractor, my father is in Excise You are working in IBM, I am interested in computers

8. The patient himself is the best person to describe his illness The sequence of events are best described by the patient Only the patient can describe the severity of symptoms

9. How can a relative or a visiting bystander tell the details How can they express the severity of the symptoms Unfortunately in our state the relatives interfere too much

10. For example the patient is comatose or aphasic The patient is in a seriously ill or terminally ill state The patient is undergoing a procedure or surgery

11. Patient sitting opposite to or by the side of the examiner The patient may be lying down in the bed, unable to sit up Then one must stand or sit on the right hand side

12. If so the patient is likely to be disinterested in the interviewer. Instead use small spiral notepads available every where This is just to note down the points not every thing patient says

13. Then the patient is likely to be disinterested Don’t write down every word the patient says Note down only thing you are likely to forget

14. Legible Full text Full sentences All headings No scribbling Underlining Coloring

15. Hence full name of the patient with initials is required Include Mr or Dr or Professor as the case may be Always address the patient by name if possible

16. Congenital heart diseases in childhood Diphtheria and measles occur in children Heart attack in middle age or old age, but with exceptions

17. Certain disease occur exclusively in males Certain disease occur exclusively in females Otherwise diseases in general equally affect males and females

18. Record the exact nature of the work of the patient Not the official nature like ‘manual laborer’ Also try to identify various risk factors & toxin exposures

19. The complete postal address of the patient is written down The address shall include the name of Post Office and PIN number The name of the next of kin is also needed, in case of death etc

20. Filariasis is very common in patients residing in costal areas Multiple sclerosis is common in temperate climates It is rare in tropical climates like India

21. The Inpatient number, number of the bed, ward, number of the unit The date of admission, the date of Surgeries Date of examination of the patient shall be mentioned separately

22. Fever, cough, sputum, dyspnoea -4 days duration Abdominal pain, nausea and vomiting – 3 days Symptoms that developing later are not routinely included

23. Along with the onset, nature, progression, offset Associated symptoms, are mentioned separately These may directly indicate the probable diagnosis.

24. They should not include any details of the history But only the symptoms and duration of each symptom against it Fever – 3 days, Cough – 2 days, Hemoptysis – 1 day

25. Use phrases when required, to describe the symptoms well For example inability to speak in full sentences Weakness of the right upper and lower limbs, Incontinence of urine

26. This requires great skill as well as patience from part of the student So one has to be a good listener first of all Only then you can become a good story teller

27. Then the patient is asked to narrate all the details of symptoms Just prompt them when ever necessary Redirect them is they are going off the track

28. Patient listening will help the patient in remembering all the symptoms If you interrupt frquently the patient will be diverted The they may not mention important symptoms

29. If you ask for radiation of chest pain to the left forearm, answer will be yes Always ask open ended questions like is there any radiation? This elicits a true answer more often than otherwise

30. For example details regarding the sputum color Ask for the frequency of sputum production Ask for the quantity, color, appearance, foul smell, or blood

31. This includes enquiry into the various cardinal symptoms These are the important symptoms affecting a particular system Making sure that there are no symptoms pertaining to the system

32. Any history of similar illness in the past; if so the details Diseases which required prolonged bed rest or hospitalization Any of the other important diseases in the past like DM2 HTN CAD PTB

33. Whether patient is a vegetarian or non vegetarian Is there constipation or frequent stools, retention or incontinence Is there Insomnia or, disturbed sleep, bad dreams early awakening

34. Smoking habits, it’s age of onset, smoking index, chain smoking Alcoholism since how long and are there intoxications or withdrawals Is there any other addictions like ganja and other drugs

35. Any similar illnesses in the other members of the family Diseases which required prolonged bed rest or hospitalization Any of the other important diseases in other members DM2 HTN CAD

36. Thank You