Clinical History Taking Format in Medicine: Physical, Systemic Examination

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Clinical history taking is an art of extracting out the smallest of information from the patient and reaching to a possible diagnosis. For Medical (especially MBBS) students and Interns, Medical History is a vital thing to learn, understand and interpret in order to become a professional Doctor. Without it, you are definitely not going to pass in the practical exams indeed. Here we present the basic layout of taking clinical history which can be used to avoid missing important points. If we still missed anything, don’t forget to point it out.

NOTE: Always remember standing on RIGHT SIDE of patient while taking the history.

Particulars of Patient

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Following are general particulars you need to note in Clinical history taking format:

1. Name
2. Age
3. Sex
4. Religion
5. Occupation
6. Address
7. D.O.A (Date Of Admission)
8. D.O.E (Date Of Examination)

History Proper

Medical History proper includes the following points:

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1. C/C (Chief Complaints)
2. HOPI (History Of Present Illness)
3. Past history
4. Personal history
5. Family history
6. Rx history (Treatment history)
7. Psychological history
8. Menstrual/Obs. history in females

Physical Examination

A general physical examination (GPE) and a systemic examination is performed during the clinical history taking:

General survey

  1. Level of consciousness- whether patient is alert, co-operative and oriented to time and space
  2. Apparent age- Patient may look younger in Down’s syndrome, Thallasaemia, Pituitary dwarf or patient may look older than his/her age in Progeria (Extremely rare genetic disorder in which aging occurs at very early age) or Precocious puberty (Development at earlier age than usual)
  3. Decubitus (Position of patient)
  4. Built- Average/Dwarf/Tall stature
  5. Nutrition- Average/Underweight/Obese (try to get BMI)
  6. Facial appearance
  7. Pallor
  8. Icterus
  9. Cyanosis
  10. Neck vein (J.V.P, J.V engorgement, J.V pulse)
  11. Neck artery (Carotid arteries)
  12. L.N (Lymph nodes all over body)
  13. Thyroid gland
  14. Clubbing
  15. Koilonychia (Spoon nails) – Hypochromic anaemia in Iron deficiency anaemia
  16. Pulse- Rate, Rhythm, Volume, Condition of arterial wall, Comparison b/w 2 radial pulses, Radiofemoral delay, any special character, Other peripheral pulses
  17. Respiration- Rate, Rhythm, Depth, Breathing pattern)
  18. Temperature- Oral temperature for Fever
  19. B.P (Blood pressure in mm Hg)
  20. Edema
  21. Skin, Hairs, Nails
  22. Height and Weight
  23. Any obvious deformity of skull, spine, limbs, swelling of abdomen
  24. General- any acute distress present or not
  25. Handedness (Right/Left) with level of intelligence (Average/Low/High)
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Systemic Examination

  1. CVS (Cardiovascular system)
  2. Respiratory system
  3. GIT (Gastrointestinal tract) system
  4. Nervous system
  5. Genitourinary system
  6. Lymphoreticular system
  7. Locomotor system (Optional)

Summary of Case

It should be in few lines, explaining the general information of patient and then key points. Always reach 5 points during medical history taking :-

  1. C/C (Chief Complaints) of patient
  2. Organ system affected
  3. Onset of symptoms (Acute/Chronic)
  4. Etiology (Infectious, inflammatory, traumatic, genetic, etc.)
  5. Possible diagnosis
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So, it could be like- Patient named xxx aged xx years presented on xx/xx/xx date with such and such complaints. xx system appeared to be affected and on examination, xx disease/symptom was revealed which was acute/chronic in onset and having xx possible etiology. The provisional diagnosis appears to be xx.

Provisional Diagnosis

The most possible diagnosis you can make out of case.

Differential Diagnosis

Make a list of possible diagnosis and rule out individually to reach to the exact diagnosis.

Relevant Diagnosis

Certain investigations like X-ray, usg, ct, etc can be asked for more detailed information.

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