Internal Medicine History Taking PDF

Made by: Farah H. Inspired by: clinical rounds- Dr.Allam’s book History taking Personal history: name- age- smoker? HTN or DM> Chest: CHEST 2P 3C -Cough: OCD- precipitating and relieving factors Expectoration**: amount-color-consistency-odour -Diurnal variation: early morning: b...

Made by: Farah H. Inspired by: clinical rounds- Dr.Allam’s book History taking Personal history: name- age- smoker? HTN or DM> Chest: CHEST 2P 3C -Cough: OCD- precipitating and relieving factors Expectoration**: amount-color-consistency-odour -Diurnal variation: early morning: bronchiectasis and bronchial asthma--Nocturnal: cardiac -Postural variation -Seasonal variation: allergy *Dyspnea ‫بتنهك؟‬ *Orthopnea ‫بتنام على كام مخدة؟‬ *Paroxysmal noctural dyspnea (PND) ‫بتصحى على كرشة‬ ‫نفس بعد ساعتين من النوم؟‬ Wheezes*- chest pain- cyanosis- syncope LL edema History of TB-sarcoidosis-lung cancer- bronchial asthma (past and family history) PS: In bronchial asthma: ptt awakens in the middle of the night with coughing and wheezing* -Haemoptysis: OCD- association **Haemoptysis vs Hematemesis: Haemoptysis Hematemesis Bright red Brownish Frothy-with sputum With food particles Preceded by cough Preceded by nausea and vomiting Amount of blood ‫قد كوباية؟‬ Need for blood transfusion (to assess severity) *** -Previous attacks Shortness of breath- palpitations- syncope or dizziness- fever Family history of bleeding disorders-cancer Expectoration: OCD- association Amount-color-consistency-odour (color is yellowish in supp infections and greenish in pseudomonas infection) Postural variation: inc with leaning forward in bronchiectasis Inc on healthy side in lung abscess Shortness of breath (Dyspnea): OCD Orthopnea-PND Others: CHEST 2P 3C Classification of dyspnea: Dyspnea grade 1: with more than ordinary effort (exercise) Grade 2: with ordinary effort Grade 3: with less than ordinary effort Grade 4: at rest Wheezes (‫ تزييق‬T): OCD- CHEST 2P 3C Chest pain: OCD-association -Site (upper-lower-right-left)-radiation Character: colicy-stabbing-stitching- dullness-burning-heaviness ‫ تقل‬-‫ حرقان‬-‫ تنميل‬-‫ غز‬-‫ طعن‬-‫ممغص‬ -others CHEST 2P 3C Nausea,.. Other systems (P: ‫)الباقي‬: -CVS: systemic venous congestion symptoms (LL edema- jaundice- anorexia) Pulmonary congestion symptoms: dyspnea- cough- hemoptysis Low COP symptoms: headache- dizziness- syncope Constitutional manifestations: fever- sweating- anorexia- loss of weight Cyanosis Systemic venous Congestion symptoms (generalized edema..) -Cardiac: 4C 4P Pulmonary congestion (left sided HF): dyspnea- cough- hemoptysis- recurrent chest infections Dyspnea: -OCD- ppt and relieving factors + association+ classification (which grade?) CHEST 2P 3C **Orthopnea ‫بينام على كام مخدة؟‬ **Paroxysmal nocturnal dysnpea (PND) ‫بيصحى على كرشة نفس بعد ساعتين نوم؟‬ Systemic congestion symptoms (Right sided HF) : LL edema (bilateral-painless-pitting) Pain in right hypochondrial region (liver congestion) Abdominal distension/ascites Anorexia (GIT congestion) -Low cardiac output (COP): Headache- dizziness- syncope- blurred vision Oliguria- fatigue Pale cold skin Cyanosis Chest pain: (any pain): OCD, ppt and relieving factors Site (retrosternal)- radiation (left shoulder- arm-jaw-back) Character 4C 4P Pressure manifestations: Bronchus or trachea: dyspnea Esophagus: dysphagia Recurrent laryngeal nerve: hoarsness of voice Palpitation ‫بتحس بضربات قلبك؟‬ BP manifestations (HTN): usually asymptomatic but if severe: headache- blurred vision- epistaxis Abdomen: Upper GIT symptoms: -Haematemesis: OCD- ppt and relieving factors Amount (needs blood transfusion?** faints?) Color- consistency- odour -Hemoptysis vs hematemesis: Haemoptysis Hematemesis Bright red Brownish Frothy-with sputum With food particles Preceded by cough Preceded by nausea and vomiting Melena-bleeding tendency? Disturbed consciousness? Nausea-vomiting-abdominal pain? Weight loss? Past history of peptic ulcer***- bleeding tendency- cirrhosis Family history of bleeding disorders- GIT problems -Nausea-vomiting- halitosis (bad breath odour)- hiccough -Dysphagia- heart burn (epigastric pain) Appetite Dyspepsia- regurgitation Lower GIT symptoms: Diarrhea (at least 3 loose stools per day) Constipation (less than 3 times per week) Tenesmus ‫تعنية‬ Dysentry (diarrhea-blood-mucous- tenesmus) Melena (dark black tarry stool due to upper GIT bleeding from oropharynx to the end of midgut—digested bood): ‫لون البراز اسود زي‬ ‫الزفت؟‬ OCD Amount (needs blood transfusion? faints?) Previous attacks? Haematemesis and its analysis Past history of peptic ulcer- bleeding tendency- cirrhosis Family history of bleeding disorders- GIT problems Distension- flatulence Liver symptoms: -Liver cell failure: ***Jaundice (yellow discolouration of sclera and mucous membranes): OCD **color of urine and stool: Clay colored stool in obstructive jaundice Dark colored urine in hemolytic jaundice LL edema- ascites Haematemesis- melena- bleeding tendency Anemic manifestations (PCDEF: pallor- tachcardia-dysnpea- easy fatiguability Disturbed consciousness (hepatic encephalopathy) Fever (by hepatitis)- abdominal pain Pruritis in cholestasis Past history of gallbladder-pancras diseases Family history of autoimmune diseases- cancer Ascites ‫بطنك عليت عليك؟‬ OCD Jaundice+ its analysis Bleeding tendency, hematemesis and melena by portal HTN Spleen symptoms: splenomegaly (left upper abdominal pain): Bone pains- tender sternum- pancytopenia=leukemia Generalized lymphadenopathy and fever= lymphoma or TB eg. Urinary system: Frequency-urgency Incontinence Dysuria Hematuria-oliguria (nephritic syndrome) LL swelling (ptnuria in nephrotic eg) Vomiting-itching (uremia: renal failure) Genital system: impotence and low desire PS: Abdominal pain: OCD- ppt and relieving factors Site- radiation Character Severity? (very severe in familial mediterranean fever ‫)بيزحف من األلم‬ Eg: appendecitis pain-ectopic pregnancy felt in right iliac region Pain referred to right shoulder: gallbladder disease Neuro: Onset: sudden : within min reaches its max: Emobolic ‫مرة واحدة لسانه تقل او ايده مش بتتحرك‬ Acute : with hours-days reaches its max Gradual: took weaks -history of similar attacks is imp -Motor: Weakness: ** OCD- similar attacks? Complete paralysis or partial (degree)? ‫شلل‬ ‫كامل وال ضعف؟‬ Hyper or hypotonia? ‫عضالتك مخشبة وال سايبة؟‬ Atrophic muscles and trophic changes ‫عضالتك خاسة؟ شعر جلدك رفيع؟ ضوافره ضعيفة؟‬ Fasciculations‫عضالتك بترعش ال اراديا ؟‬ Distributuion: UL or LL or both Uni or bilateral or both Proximal or distal muscles UL-LL: ‫تقدر تسرح شعرك؟ تعصر ليمونة؟‬ ‫تقدر تلبس الشبشب؟ لما تقعد في األرض وتقوم الزم‬ ‫يسندوك؟‬ Gait ‫مشيتك اختلفت؟‬ Sensation: sensory loss: OCD.. Distribution Character (pain: hyperalgesia or just numbness, tingling: hypoalgesia) ‫‪Cranial nerves affection:‬‬ ‫عندك مشكلة في النظر بعد الجلطة؟ ‪X optic n.‬‬ ‫جفنك ‪X occulomotor-trochlear- abducent‬‬ ‫ساقط؟ عينك احولت؟ بتشوف الحاجة اتنين؟‬ ‫فيه شكشكة او تنميل في وشك؟ او ‪X trigeminal‬‬ ‫صعوبة مضغ؟‬ ‫األكل بيتجمع في الفم؟ ‪X facial‬‬ ‫ريقك بينزل؟‬ ‫الفم اتعوج؟‬ ‫عينك بتقفل وال أل؟‬ ‫‪X vestibulococchlear‬‬ ‫)‪X 9-10-11 (palate-parhyx-larynx‬‬ ‫هل األكل بيرجع من األنف؟ صوتك مخنف؟‬ ‫بتشرق وتكح مع األكل كتير؟ صعوبة بلع؟‬ ‫بحة صوت؟‬ ‫لسانك تقل؟ اتعوج؟ ‪X hypoglossal‬‬ Increased intracranical tension (ICT) symptoms: Projectile vomiting-blurred vision- severe headache at morning- convulsions- disturbed consciousness level Speech ‫لسانك تقل؟ عندك لخبطة في الكالم؟‬ Sphincters: urine and stool incontinence? Constitutional symptoms: anorexia- weight loss- fever- sweating Past history: DM-HTN- rheumatic heart disease (thormbi in mitral valve->emboli to brain)- TB