eSigning Past Medical History Form Made Easy

Esigning past medical history form

today we begin with the history taking and general examination which is the topic of clinical physiological name what is the importance of a good history it frequently affords a lead in the right direction or clue to diagnosis first elicitation of various characteristics of pain messages its true nature as one of angina pectoris renal colic acute appendicitis or duodenal ulcer it rules out or eliminates certain diagnostic possibilities it suggests further Avenue of Investigation it helps to focus the observers attention to the system or system involved since symptoms usually precede science the history may a fourth a real proof of disease than a clinical examination so all these are the importance of history technique now we are going to see which are the steps of the history taking presenting a case of 65 years old married or unmarried Hindu male or female named ABC working as or studying PQR residing at X Y Z of lower middle or higher socioeconomic class admitted to g1 war on the date so you have to write on the date on which you are taking the history or either you can take history in the war or in the OBD so came to medicine Oh Polly or you have to write the respective OPD in which you are taking the history with the following chief complaint so that is the basic paragraph which every history must have to follow presenting a case of 65 years old married or unmarried Hindu male or female so in this cases you have to ask the of your patient either he is married or she is married or unmarried male or female then you have you noticed and named you to ask the name of the patient working as or studying if he is a student then you have to write the studying at this institution in this course or working you have to write in this field at this place etc so working is or studying PQR residing at XYZ residing it means you have to write the full address of your patient and so you have to ask your patient about their socio economical class and admitted to GE one one so I am just giving you example that the g11 in whatever the word you are standing or taking the history you have to write if you are not taking this history in the war then here to write the respective name of the OBD and with the following chief complaint so that is the basic philip graph for all the history in the all the departments so you simply have to write presenting a case of 65 years old married hindu male named ABC working as laborer whatever the thing is residing at of 53 these these society these address pool of the address of lower socioeconomic our class admitted to g11 on the date so today's date move is the 13 January 2019 so that is what you have to write and with the following chief complaints here the most important thing why we have to ask for age the age of the patient may so to suggest certain diagnostic possibilities and rule out others for example degenerative neoplastic and was pure elements are more common in the middle-aged or elderly infectious fevers and congenital anomalies are common in childhood so that's why we were to ask the age of the patient now the sex certain disease such as cerebral hemorrhage coronary thrombosis hemophilia and malignancy of the tongue and stomach so a special affinity for the male sex others such as thyroid disorders and memory cancer so a similar prediction for the female case so that's why we have to see the sex of the patient now occupation or the trade of the patient may at times of what a clue to the diagnosis for example lead poisoning is common in plumbers and painters pneumoconiosis in silica workers and coal miners that's why be able to ask the occupation of the patient residential address of the pace and may serve to focus once attention on the various environmental factors which may involve and may also prove useful in the subsequent follow-up of the case so residential address with the house number you must have to us because sometimes a patient came for example of the malaria and we have to find out whether the same cases are present in the same area or not that's why we have to need the house number as well as the whole residential address of the patient chief complaint the first step in the history taking after the recording of preliminary data is to state quite briefly the exit nature and duration of the chief complaint or the presenting symptoms so chief complaint is the next step brief history about the main presenting complaints which lead the patient to you so in this chief complaint you have to write only the complaints which patients have and which patients leads to you and you to write the oldest complaint first for example pain in a bromine since four days so here it is not an axe pain in abdomen since four days the oldest complain to write in the first and the whatever the recent complain here to write later on so vomiting since two days for example the next complaint will be the weakness since one days so you have to write in this manner so pain in a province since four days vomiting since two days weakness since one days likewise you to write here the chief complaint must be in the patient's word only for example patient date that he is or she is having the pain in a bromine than here tonight pain in a bromine if the patient saying that he is having the difficulty in breathing then in you have to write difficulty in breathing sing these days but never tried to use the word dips near a patient said that they having the difficulty in swallowing so you have to write difficulty in swallowing since these days never tried to use the word dysphasia all right after the chief complaint you have to ask the origin duration and progression or ODP of disease or history of the present illness so in this case we have three complaints pain in abdomen vomiting and the later one I told you about the weakness so you have to ask the origin duration and progression of pain in a bromine origin duration and progression of vomiting and origin duration and progression of weakness elaborate every complaint in detail about its origin of time and how it is progressed to the current position in this section you have to write paragraph like manner and every complaint in detail for example starting with the patient was asymptomatic before four days gradually he or she develops pain in a blow main the pain the every characteristic what what will be the time of the pain at in the morning in the evening in the afternoon after meal before meal or everything about the pain here to mention in this paragraph so this section represents the origin relation and progression of disease or history of the present illness now the next section is of the past history in which you have to ask your patient about the diabetes hypertension tuberculosis jaundice whether it is present or not and you must have to us whether the similar chief complaints if he or she had in the previous few months back or not and if you are not able to find any positive or significant thing then you just write not significant past history in this section all right the next is the family history if the same complaints are present in family members or they have diabetes hypertension or such chronic disease so you have to write in this family history section and if you are not able to find any significant or positive family history just write not significant family history after this the next is a personal history in this personal history you have to ask for the diet diet it should be the wage or mixed sleep you to write the adequate seven to eight hours nightly sleep so you have to mention that bowel and bladder habits menu in a scientific Asian whether it is normal or not addiction in this addiction section you have to mention the exit time duration content of the product he or she is addicted to for example someone is addicted to tobacco then you have to write the which tobacco product he or she is using at which time since how many years everything about the addiction you have to mention and if you are taking the psychiatric history then you must have to mention of the social media Ericsson - in this section next is the menstrual history in female patients ask for any irregularities of the menstrual cycle after the completion of the history taking now we begins with the general examination in the general examination section we have to see whether the patient is conscious cooperative and well oriented to time place and person or not so here what will happen pace and maybe conscious semi-conscious unconscious so you have to find out the consciousness of the patient and whether it is cooperative you just you have to ask the patient what's your name where you are sitting what's the timings running right now either it's a morning afternoon or evening or night what does what is the name of your relatives what is the name of your father or daughter that's how you will find out patient is conscious cooperative and well oriented to time place and person so your first sentence would be like this after that you have to record the vitals in these vitals there is a mnemonic which is t PR BP t for temperature P for pearls are for respiratory rate and B for blood pressure so you have to record the vitals temperature pulse rate and respiratory rate and blood pressure once the vital is recorded now you have to look for the general science I think everyone is knowing about what is symptom and what is sign symptom means everything which patient tells to you what the complaints which patient tells to you and sign means whatever the doctor sees in the patient so here it's a mnemonic police P for Baylor o for edema and for lymphadenopathy I for icterus C for cyanosis and clubbing so you have to see for the police or general science which is paler edema Limpy but the it terrors cyanosis and clubbing in my next lecture or the part two of this history-taking internal examination you will find out how to see all this general science in the patient after this general science you have to check thoroughly about the head-to-toe examination starting from the hair skins forehead eyebrows eyes Clara nose lips tongue cheeks Nate everything you have to see thoroughly starting from the head Tilda - so that is known as head to toe examination once you complete your head to toe examination thus first subtitle is of the systemic examination there are four systemic examinations first one is the cardiovascular system respiratory system abdominal system and central nervous system depending upon the chief compliance you have to examine the specific system for example our chief complaint is pain in a bromine vomiting and weakness so it indicates us that patient having the abnormality related to the abdominal system so in this section we are going for the abdominal systemic examination for example if a patient complain of the left-sided chest pain as well as difficulty in breathing then we will examine the cardiovascular system that's how you have to choose with system you have to examine for example some patient having the dual system involvement so in this cases you have to examine the both the systems so the main headings of the systemic examination for all the system is inspection palpation percussion and auscultation so these are the four parts of the systemic examination I will describe in detail about every part in my next session or the part 2 of the history taking and general examination so please wait for that please remember everyone must have to follow the systemic examination in this order only first would be the inspection seconds would be the palpation third one is the percussion and fourth one is the auscultation all right after the completion of the systemic examination we have to give the provisional diagnosis if certain type of investigations are needed then we have to prescribe the investigations once we see the proper investigation for example blood tastes different type of blood taste CT scan x-ray depending upon their chief complaint we will go on the final diagnosis so we have to give the final diagnosis what the patient having or what the disease the patient is suffering from after that last is the treatment part so these all are the steps of history taking one more time I am going to devise you presenting a case of 65 years old married Hindu male named ABC working as a Libra residing at this address of the lower socioeconomic our class admitted to this war on dead these and came to medicine operated with the following chief complaints for example pain in abdomen since four days and vomiting since two days after that section you have to go for the origin duration and progression of the disease or the history of present illness after that you have to ask for the past history next is the family history in the section of personal history or to ask for the diet sleep bowel and bladder habits and addiction mention early in case of female patients then general examination in this direct examination section you have to write the patient is conscious cooperative and well oriented to time place in person if he or she is otherwise you have to write down according to this white tells you have to record the temperature pulse rate respiratory rate and pressure of the patient after that you have to see for the general science for example paler edema lymph adenopathy icterus cyanosis clubbing etc once you completed your general science go for the head-to-toe examinations now this first subtitle is the systemic examination system examination should be performed in this manner inspection palpation partisan and auscultation after you complete or systemic examination there will be the provisional diagnosis you have to provide the provisional diagnosis but to confirm the provisional diagnosis we have to certain type of investigation must have to do so investigations next one final diagnosis after we check our investigations we have to give the final diagnosis and once be having our final diagnosis the next part is the treatment of the patient you