Arts of History taking for interns and Neurology residents

detailed description on arts of History taking for interns and Neurology residents

1. Arts of History taking Dr. Chirayu Regmi Resident, Neurology MD, Internal Medicine UDM-NINAS

2. CHIEF COMPLAINT

3. HISTORY OF THE PRESENT ILLNESS HISTORY TAKING Dimensions: Onset, duration, location, progression, frequency, intensity, character, nature (intermittent or continuous), effect of physical measures, precipitating and relieving factors, associated symptoms, and type & effectiveness of previous treatment.

4. REVIEW OF PATIENT-SPECIFIC INFORMATION history of medical and surgical illnesses ; current medications and allergies; a review of symptoms in non-neurological systems of the body ; the personal history in terms of occupation, social situation, and alcohol, tobacco, and illicit drug use; and the medical history of the parents, grandparents, siblings, and children , looking for evidence of familial diseases

5. Review of Systems LOBAR HISTORY: (F) : No history of abnormal behavior or personality, irrelevant talk, urinary disinhibition , aphasia, (P) : difficulty reading, writing or understanding spoken language or finding way to his room in house (T) : impairment of memory, emotional lability , intense fear, excessive feeding, intense sexual drive (O) : Narrowing of vision, difficult differentiating colors or distortion of image, scotoma , intermittent blindness

6. CEREBELLAR: Disbalance , tendency to fall, abnormal movement of hand or head or eyes

7. CRANIAL NERVE: There is no history of loss of smell, loss of vision, inability to perceive color, diplopia, facial numbness or hyperesthesia, no difficulty in chewing foods, facial deviation, drooling of saliva or hyperacusis and perceive taste of food, hearing impairment, can swallow food and liquid without nasal regurgitation and intonation of voice, can move head to either side and propel food by his tongue.

8. ENDOCRINE: No history of cold or heat intolerance, sweating in hands, decrease libido and erectile dysfunction, increase in the size of breast, discharge from nipple(female), No increase in size of facial structures or size of fingers or toes or loss of axillary hairs or testicular atrophy SPINE: Back pain with radiation, claudication distance, aggravation during night (biological) relieved with bending, rest or standing, associated trauma or fever or constitutional symptoms and involvement of bladder and bowel habit.

9. OTHER NEGATIVE HISTORY: abnormal movement of body, fever, trauma OTHER SYSTEMS

10. History of Previous Illnesses

11. Family History

12. Social History

13. THANK YOU