Dr.r.m.nakum & Dr.t.r.

nakum

Subject: medical case taking

Telephone no. : 9426458902

Medical Case Taking

O.p.d no. .. Bed no. . i.d.p no. date of admission..& time. Date of discharge.& time. Name..age.. Sex.Religion Occupation Address.

Chief complain : Chromological way O.p.d.:- chromological way

 Personal history:1. Hebits:- like tea,coffee,sigar,bidi,alchohols. 2. How much per day? 3. Work:-hard or light. 4. Sleep:-sleepless,abnormal / normal.. is their any dream / not ? if there is then what type . 5.bath:-likes- cold or hot 6.appetite-normal / increased / dicreased 7.desire for hot / cold food. 8.aversion 9.thirst:-normal / increased /dicreased Quantity at a time- large / small, likes hot / cold water. 10.bowel:- moved or unmoved:-time- day / night, normal/ watery/ profuse/constipasion.present of mucous/blood.pain- (1)before /while/after (2) characteraggravated by / amelioration. odour of stool/colour/quentity 11.urine:- day/ night ( quentity) Pain-(1) before/while/after passing urine

(2)aggravated by amelioration - Colur & odour - Present of pus cells /stone /blood 12. leucorrhoea :- day / night Colour/ odour Acrid / not Watery/ profuse/ scanty 13.perpiration:- scanty / profuse/ abscence/ odour 14.mental:- co-operative / not 15.diet :- which type ? it is rich / carbohydrate/fat.

Past History:-h/o of major illness such T.B.,diabetes,jaundice,artheritice,psychic,illness,typhoid,rheumetic fever,s.t.d.,asthama,pneumonia,circulatry disease,any major hypertension etc -h/o past treatment -h/o of vaccination- in child hood or adult & name of vaccination. -h/0 of any operation ,radiotherapy,psychotherapy. -h/o of any hypersensitivity of any drug.

Family History :merried / unmerried /widow/widower. No. of family members. No. of children- male/ female Family history of any heriderory disease, meternal/parental side. Family history of any major illness as T.B.,diabetes,jaundice,artheritise,psychic illness,hyper/hypo throdism,Rh.chorea,any skin disease,Rh.fever,asthama,allergic disease

1.Physical General Examination:constitution:- Make of body 1.built of patient 2. Weight patient & hight patient 3. State of nutrition good / not4.obesity/oedema present / not. 5.skin:colour,oedema,anaemic,cyanosis,lex,pigmentation,dehydrated,petchiation,erupti on,ulcer,spider neavy,swelling,deformities,respiration,pulse,temperature.. B.P.- sy/di.mm of H.g. 6. relation with heat and cold. 7. Miasm:-psora/syphilis/sychotic 8:- diathesis:scrofulous,raechitic & tubercular , Rheumatic,haemarrhagic 9. Temperaments:bilious,nervous,leucophlegmatic,limphetic,sangmine,melancholic.

2.Head:- colour of hair

-Lustry present / not.,dendruff,lice,texture.area of scalp covered.,injury marked on head, bony deformity on scalp., irruption under hair, acne on fore hair.,size of head normal/big/small. -Headache:- A. causation B. location C. sensation D.character of headache E. character of pain F.modality G.concomitent

3.Eyes:Eyelieds:-inflammed /not. Injury /not. Ptosis / not. 1.Reflexes :- conjuctival reflex, corneal reflex. 2.Field of vision:- normal/ disturb Conjuctiva:- color . Inflamation/not. Sclara:- colour. Pupils:- size or equility. Reaction of light:- acomodation Lacrymation-quentity.aglutinated/not.

4.Ears:Skin surrounding ear. Otorrhoea present /not. Odour/colour/quentity Sence of hearing normal/disturb. Deafness:-parcial/perment Presence of oedema/not. Position to bule..

5.Nose:Condition of septum- normal/ deviated Nostril- colour dry /moist. Sense of smell present or not. Coryza:- present or absence-if there is then causative factor,colour,character of discharge like watery /profuse/scanty. Acrid or not. Modality:- < by &> by.

6.Mouth:Breath- odour A. Lips :- colour, cracks/ fissure B. Teeth:- hygenic or not. Number of teeth., pain- character & <by & > by. If teeth removed why? C. Gums:- colour,bleeding/not., sweeling/spongy/ulcerated D. Buccel mucosa :-colour,pigmentation/not. E. Palate:-movement of soft palate.ulcer present / not. F. Tonsil:- inflammed /not.state of tonsil-bleeding /not.any ulcer G. Tongue:-colour,coating/not,edges,ulcerated/not.,sweeling/not,sense of tenting/not,presense of imprint of teeth. H. Pharynx-inflammed/not.colour of pharynx.,soreness/not,change of voice,cough/not.,expiration,colour,quantity.

7. Neck:-

Movement,vein visible/not.,inlarge.not., Corotide pulse-palpated /not. - Lymphglands inflammed /not? ( like anterior or posterior diognosis of lymphgland and supra clavicular groups of lymph gland). -Trachea:- deviated/not. -thyroid- inlarge/not.

8.Upper Limb:Axilary lymphnodepalpeble/not Fingers nail- clubbing or koilonychea Pulse:-pulse rate,rythum,volume,condition of vessel wall. B.P..mm of Hg. - joint reflexes -if oedema-pitting on pressure/not

9.Thorex:Size & shape of chest. Depth & character of respiration. Pulsation:- apex beat visible / not? Chest:- chest symentrical / not? Thill:- pericardium thill present / not? Voical :- resonance normal / not? Spine :- movement / not? Deformitis of spine Brest:-areola- pigmented / not? Nipple- inverted or everted.cracks & fissure present / not? Cloastrum present or not. Brest vein visible or not?

10.abdomen:Size symentrical or not? Distended or not? Abdominal wall movement or not? Vessels dilated or not? Parastaltic movement visible or not? Hermal orifice present or not? Impulse of coughing. Abdominal wall wrinked or not? & colour Abdomen or inverted / everted. Umbellicus- any deformity present or not? Umbellicus inverted / everted.

11. lower limb:Oedema present or not? Pitting on pressure or not? Varicose vein present or not? Skin erruption on leg & feet present or not? Joints inflammed or not? Reflexes knee,planter , norman or not ? Pain character :-< by & > by . Pain Ulcerated or not with other joint pain. Peripheral pulse :- femoral, poplitial, posterial tibial artery.. per / minute.

Systemic examination :-

1. Respiratory system :(A) Inspection :- shape of the chest Any disease of vertebral colume . kyphosis ( for word banding). Scoliosis ( back word banding ). Deformity in chest. Chest symentrical or asymentrical. Movement of chest on both side. Apex of the chest flatten or not? Respiratory muscles prominent or not? Respiratory rate/ min. Expiration & inspiration prolonged or normal? Expantion of chest normal , diminish or absense.

(B) Palpation :- any swelling on chest or not? Sweeling fluctuate or not? Trachea place centraly or deviated? Position of cardiac inpulse displace or not? Nature of respiratory movement . Two side of chest move at same extent or variation. Any vibration of chest or not? Vocal fremitus increase or decrease. (c)percussion:- character of sound (1) dull or resonance (2) same on both side or deffere. Resonance sound hyper resonance or diminish.

(D)Ascultation:- cheracter of breath sound vesicular or bronchial? Character of vocal resonance :-1. presence or absence of other sound, 2.pause between ,inspiratory or expiratory,3.Rhonchi, cripitation,viseing ,plural rub.

(E)Throat:- see diptheria,tonsillitis.larryngitis,pharyngitis,soreness present ot not? Difficulty in sweeling is present or not? Causation , location, sensation,character of pain,colour of mucous membrane Modality < by & > by, concomitence.

(F)Nose:-coryza causation. Character & colour of discharge, Modality :- < by &> by. (G)Lung:-pneumonia :-(a) causation (b) site of lung is affected(c) character of cough(d) character of sputum(e) look of the face.(f)concomitent(g)modality:<by &> by. (H) X-ray & scaning :-find out the disease like pulmonary function,bronchial asthama,pmeumonia,lung abscess pulmonary tuberculosis,bronchogenic carcinoma, pulmonary oedema pleurisy.

2.cardiovascular system:(A)inspection:- dysponea & disease present or absence. Shape of chest. Neck vein visible or not?> Vein on the chest wall visible or not? Cardiac impulse position apex beat displate or normal. (B)palpation:- other pulsation:- suprasternal notch , cardiac pulse,pulsation of epigastrium. -thrill:-( any sound or murmur). Palpable or not? (c) percussion:- any dullness detected or not? (D)auscultation:- any diviation of the sound,any mermer present or not? Any splitting of heart sound detected or not? Rhythum of sound normal or abnormal

Murmurs- systolic , diastalic, continues through out systolic / diastolic. Arterial pulse:-rate of pulse, rthythum- regular or not?, volume,condition of vessel wall. (E)X-ray & screening :Any congenital heart disease Valvular heart disease, Ischemic heart disease Myocardial heart disease, Pericarditis, Disease of vessels (F) Heart:Cause of heart disease, Sensation, Character of pain & symptoms Modality < by & >by. Concominat.

3.digestive system:(A) inspection:-shape of abdomen:normal/fullness/protruberance/sunken. Fullness: symentrical/ asymentrical Circumferance at paint of maximum distension. Bulging local zone or generalize. Any pulsation in epigastrium. Movement of the abdominal wall.

Bulge during inspiration & full duaring expiration ( rev:- inparalysis of disphragm) Surface of abdomen:- smooth / glossy. Any distention of surface vein. Pigmentation of abdominal wall present / not? Appearance of umbellical:- everted /inverted? Presence of wax or not? Site of hernia- femoral/ingivinal (B)palpation:- rigidity:- local / general or tenderness. Any unusual swelling of abdomen or not? (1)Liver:-1. Lower edge of liver palpabel or not? 2.character of surface:- tender,soft,firm,hard,smooth,nodular (2)gall bladder:- any felt when distended. Murphys sign gall bladder tender/not? (3)spleen:- spleno megaly:- minor/ major. Edge of pleen- sharp/ smooth. (4) kidney:-bimanual palpation Kidney enlargeor not? Displace (5)intestine:- palpated when obstruction of it.

(C)percussion:1. liver:-dullness or resonance ( air poten) 2.spleen:- spleenic dullness increase or normal? For fluid in peritonium (a)shifiting dullness present or not? (b) fluid thrill present or not?

(c)horse shoe shape dullness present or not?

(D)Auscultation:Bowel sound /murmur present or not? Silent abdomen (inactive bowel) Excessive sound ( intestinal obstuction) Sound reduce or absent. Any friction sound in spleenic region.

(E)Per rectal examination:1. by proctoscopy & sigmoido copy See presence of any eruption,external haemorrhoids & fissures or fistula. - in male see the prostate is palpated or not? - In female the cervix wall be feel projecting back & fill the mucous membrane for polyps,ulcer & tumours.

(F)Mouth:-lip,tongue,teeth,palate, gum,larynx,pharynx,tonsi l& mucous membrane ,teste. (G)Oesophagus:-difficulty in swelling liquid/solid? (H)stomach:- causative,sensation Character of pain ,vomiting ,colour,odour & consistancy. Modality:-<by & >by

(i)

Diarrhea & disentry / constipation:Causative factors Character of stool. Character of pain.

Modality:-<by & > by Concomitents

4.genito urinary system:male genitalia:(A)inspection:-1.note the pubic hair 2.the appearance & size of penis. 3. Presence & absence of prepuce 4.site of the external urethral orefice.5.circumesides or not ?6. inspect the scrotum for redness ,swelling,oedema or distension .7.hernia is present or not? 8.pubic capitis is present or not? (B) palpation:-1.palpate the panis for any induration of the corpora cavernosa.2.for any induration swelling or ulcer of the glans.3. prepuce is retracted and then drawn forwards over the glans.4.phimosis & paraphimosis 5. Is there presence of any tenderness in scrotum? 6. The inguinal lymph nodes palpable or not? 8.the size and consitency of each testis & epididymis 9.prostatic gland seminal vesicals palpable by P/R examination or not? Or not?

Female genital examination:(A) Inspection:-1. presence of any swelling 2.presence of pubic hair 3. Hymen is inspected or not? 4.is there prolapse uterus? 5. A hernia is present or not? 6.pubia capitis is present or not? 7. Nay discharge present or not? (B) Palpation:-1.palpation of pelvic flor & pouch of douglas 2.by bimanual digital examination, is there any over growth 3. Is there any swelling & tenderness?

Excretary:(A)kidney:-1. palpable or not? 2.is displaced? 3.is inlarged?

(B)the bladder:-1.genery not felt,if it is greatly distended with urine, can be felt above symphasis pubis. 3 .is there is displace towards right or left side which can be determind by percussion. (c)urine:- see personal H/O. (D)leucorrhoea:- see personal H/O.

5.central nervous system:(A)mantal

state:-1. is his memory normal? 2. Is his behaviour normal? 3.can he

dress & undreaa himself? 4.is the history given accurately, conciously with insight? (B)Gait:- 1. Is it spastic,hemiparatic,ataxic or parkinsonion? 2. Is there a foot drop? (C)

cranial nerves:-1.test ocular movement, looking for

nystagmus. 2.test facial

movements.3.test tongue protrusion & palate movement. (D)visual

field:-1.is there a hemianopia? 2. If so it is hemonymous,by temporal

unilateral or some thing else? 3.is central vision normal? 4.can be read small print with / without glasses? Fundi:- 1.is papilloedema present or not? 2.is optic atrophy present? 3.are there hypertensive,uracnic or diabetic changes present? (E)motor:-1.look for cerebellor ataxia in the limbs.2.is there any weakness of the outstretched upper limbs? 3. Is there distal proximal weakness or wasting? 4.is muscular tone normal, spastic or extrapiramidal in type? 5. Assess the tendon reflexes & planter responses. (F)sensory:-1.test position sense in the fingers & toes vibration sense in the feet.2.test pin prick in the four limbs & on the face 3.light tourch need only to be tested,if the patient complains of numbness.

Provisional diagnosis
Laboratory investigation
(1)blood report:- Hbgrams/100ml , Tc: % cmm, Dc:- neutrophil% , lymphocyte..% Eosonophil%, monocyte% Basophil..%, R.B.C.milian/Cmm ESR (2) urine report:(A)emerl exam:- Appearance,colour.,reaction,specific gravity.. (B)chemical exam:-albumine,sugar.,acetone,bile salt,bile pigment.. (C)microscopic exam:-RBC./H.P.F, puscells., epi.cell./H.P.F, sperms,crystals..

(3)stool report:(A)macroscopi exam:- appearance., colour..,blood.,mucous.,parasite (B)microscopi exam:-ova,larva,RBC.,pus cell.,macrophage..,starch,crystal. (C)chemical exam:-reaction..,occult blood..

Flouros copy advise for :-1. X-ray, ECG. Differential diagnosis

Final diagnosis Treatment