How to take a good Case history: Database

Here is an outline first to familiarize yourself with the information to be extracted and the examination points to look for.
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CASE HISTORY
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Name / Age / Sex/ Occupation
Religion
Address


Date of birth/ Date of history taking

Chief Complaints

History of present illness

History of past illness
Medical/ Surgical

Obstetrical history
•Present
Gravid index

•Past
Year/ age/ I/ II/ III/ Delivery/ Baby


Abortion history
Year/ age/ Trimester/ How it started




Contraceptive history



Menstrual history
Menarche/ Menopause/ Cycles


Marital history
Duration/ Type

Personal history
Diet/ bladder/ bowel/ sleep/ smoking/ alcohol/ drugs

Drug history
Drugs/ indication/ duration/ compliance/ control



Allergy history

Family history
Diabetes/hypertension/asthma/thyroid/cancer/T.B
Twins/genetic anomalies/bleeding disorders


Pedigree analysis

Social history
Environmental sanitation
Pets
Similar Sibling history



Birth history
Apgar score


Dietary history


Developmental history


Immunization history


Psychiatric history






General Examination

General appearance
Facies
Physical age
Built
Nutrition

Skin
Itching/lichenification/lesions/pain/paraesthesia/mole/color change

Weight/ Height/ BMI/ BMR

Pallor/ icterus/ cyanosis/ edema

Clubbing

Lymphadenopathy
Group/ status


Hydration status

Oral hygiene/cheilitis /angular stomatitis

Thyroid


Breast

Temperature/ pulse rate/ respiratory rate/ B.P.

JVP

Hernial sites



HEAD –TOE
Face/ Hair / Brow / Eyes /Nose/Mouth/Oral cavity /Neck/Chest/Abdomen/Periphery


Motor function
Upper limb / lower limb



Sensory function

Genitourinary problems

Lower back pain

Easy bruising




Anthropometry
Mid-arm circumference / Chest circumference / mid-thigh circumference


Hip-waist ratio / arm span / UL:LL ratio









Systemic examination
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•C.V.S
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Inspection
Apex beat
R.V.heave
Intensity
Symmetry
Muscle mass
Trachea
Scar
Pulsations-Epigastric/suprasternal/Parasternal
Dilated veins


Percussion

Palpation
Apex beat
location
trachea
thrill
heave



Auscultation
S1
S2
S3
S4
Snaps
Clicks
Murmurs

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•R.S
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Inspection
R.R
Symmetry
Shape
Movement
T: A-P ratio
Deformities
Flattening
Trachea
Apex





Palpation
Movement
Apex
Trachea
Vocal fremitus
Percussion



Auscultation
Breath sounds
Type / intensity /rhonchi / crepitation







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•GIT
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Inspection
Shape
Umbilicus
Stria
Scar
Pulsations
Abdominal Circumference
Cirrhosis stigmata


Palpation
Superficial
Deep


Percussion
Shifting dullness
Fluid thrill


Auscultation


•Renal


•Liver


•Skin

•Breast examination



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•C.N.S
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•Sensory

Touch

Pain

Temperature

Position

Vibration

Two point localization

Two point discrimination

Stereognosia

Graphaesthesia

Sensory inattention


•Motor
Bulk

Nutrition

Tone

Power

•Reflexes

1.Sensory

Corneal/conjunctival
Jaw jerk
Gag reflex
Abdominal
Plantar


2.Motor

Biceps
Triceps
Supinator
Knee
Ankle
Clonus


•Gait


•Cranial nerves
I

II

III IV VI

V

VII

VIII

IX X XI

XI

XII


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EYE
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Complaints

Decreased vision
Diplopia
Night blindness
Day blindness
Foreign body sensation
Redness of the eye
Watery eyes
Swelling around the eye
Photophobia
Ptosis
Dry eye
Headache
Colored haloes
Floaters
Flashes
Dandruff in eyelashes
Color blindness


History of present illness


History of past illness


Risk factors


Examination
•Functional
a)Visual acuity
Distant vision
Near vision
Pinhole vision

b)Color vision

c)Visual field

d)IOT
e)Fundoscopy





•Structural
I.Facial symmetry

II.Forehead wrinkles

III.Extra ocular muscles –
Head posture
Hirschburg test
Cover test
Ocular movements
Convergence test

IV.Eyebrows

V.Eyelids–
•Inspection

•Palpation
Ptosis /retraction/lagophthalmos

•Rate of blinking
•Swelling
•Lid lag

VI.Lid margin

VII.Eyelashes – trichiasis/madarosis/poliosis/blepharitis/distichiasis

VIII.Lacrimal punctum

IX.Lymph nodes

X.Conjunctiva - bulbar/palpebral
Congestion/hemorrhage/discharge
Degenerative changes – pinguecula/pterygium
Papillae/follicle

XI.Sclera

XII.Cornea – transparency/sheen/size/shape/sensation

XIII.Anterior chamber

XIV.Iris
XV.Pupil
XVI.Pupillary reflex
XVII.Lens



---------------------------------
ENT
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Complaints

History of present illness

History of past illness


Examination
1.Ear

•Structural
Pinna
EAM
T.M.
E.T.

•Functional
Rinnes
Webers
ABC
Otoscopy
Facial nerve


2.Nose
•External
Anterior rhinoscopy

3.PARANASAL SINUSES


4.Oral cavity
Gingivobuccal sulcus
Gums
Teeth
Retromolar trigone
Buccal mucosa

Tongue

Pharynx
Uvula
Soft palate

Hard palate
Tonsils

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Locomotory System
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Neck



Spine




UL



LL

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Diabetic Foot
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Bulk
Nutrition
Skin
Joints/Contractures
Nails
Ulcers
Hygiene
Sole
Tone





Power





Sensations




Reflexes
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Blood group
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