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History Taking(1)

The document outlines the process of history taking and general examination for general practitioners, detailing components such as personal history, complaint analysis, past and family history, and socioeconomic state. It also describes the general and local examination procedures, vital signs, and necessary investigations including laboratory tests and imaging. Finally, it highlights the importance of diagnosis and treatment options, which can be medical or surgical.

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11 views

History Taking(1)

The document outlines the process of history taking and general examination for general practitioners, detailing components such as personal history, complaint analysis, past and family history, and socioeconomic state. It also describes the general and local examination procedures, vital signs, and necessary investigations including laboratory tests and imaging. Finally, it highlights the importance of diagnosis and treatment options, which can be medical or surgical.

Uploaded by

2kdnbjx7hs
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Summary of history taking and general

examination for general practitioner


1. History
2. Examination
3. Investigation
4. Diagnosis
5. Treatment

History
• Personal history
1. Name ‫اسم حضرتك اي‬
2. Age ‫عندك كام سنه‬
3. Sex
4. Occupation ‫شغال اي‬
5. Marital state ‫متجوز؟ عندك اوالد ؟ اصغرهم كام سنه ؟‬
6. Residence ‫ساكن فين ؟ مولود وعايش طول عمرك هناك ؟‬
7. Special habits ‫بتشرب سجاير او خمره‬

• Complaint ‫اي شكوة حضرتك‬


• History of present illness
1. Analysis of complaint
2. Symptoms of the related system
3. Systemic Review
4. Investigation . treatment

• Analysis of complaint
• Onset – course – duration ‫الشكوي ظهرت امتي ؟ ظهرت فجأة وال بالتدريج ؟ بتزيد وال‬
‫ثابته وال بتقل‬
• Association ‫في اعراض مصحوبه معاها‬
• What increase ? What decrease ‫اي اللي بيزودها واي اللي بيقللها‬
• Effect of ttt ‫خدت عالج ؟ جاب نتيجه‬

+3 variants

• Postural ‫عندك بلغم بيزيد في وضع معين‬


• Diurnal ‫بيزيد بالنهار وال باليل‬
• Seasonal ‫بيزيد او بيقل صيف او شتاء ؟ ربيع او خريف‬

+3 for any excreta

• Amount ‫كميه اد اي‬


• Content .color ‫مكوناته اي ؟ لونه اي ؟‬
• Odour ‫ريحته اي‬
+3 for any pain

• Site
• Character
• Radiation

Past history ‫عندك امراض مزمنه ضغط او سكر ؟ نقلت دم اوعملت عمليات قبل كدا ؟ماشي‬
‫علي ادويه معينه ؟‬
Disease Operations Drugs
D.M Any operations Cortisone

HTN Blood transfusion Contraceptive pills

Family history
• Consanguinity ‫باباك ومامتك قرايب‬

• Similar conditions

Socioeconomic state
• Low socioeconomic state . Infections

• High socioeconomic state . HTN

Menstruale history in females


General examination
• General condition & attachment & appearance
She looks ill with cannula in left forearm

• Mentality : patient is full conscious


• Vital signs
1.pulse
• Rhythm : regular

• Rate :60-90 beat/min


If present any other abnormalities see cardiologist
2.Blood pressure : 120/80 mmHg
3. Temperature: 37.1 °C
4. R.R.: 16 cycles/min

5. Random blood sugar

Local examination
• Inspection
• Palpation
• Percussion
• Auscultation
Investigation
Scheme for investigations
1. Laboratory: Urine/ stool/ blood/
CBC/CRP/ESR
2. Images:
• Echocardiography & Doppler.
• C.T. MRI
• X ray
• Abdominal ultrasound
3. ECG
4. Endoscopy
5. Catheterization
6. Biopsy

Diagnosis:
Treatment
1. Medical
2. Surgical
Made by Dr mohamed Uossry

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