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EXAMPLE OF INTERNAL MEDICINE'S HISTORY | DOWNLOAD HISTORY (PDF FILE)

This article based on clinical medicine course because that course deals with the taking of history of patients during the hospital. Each history has its format and principle by simple meaning the difference of history is depend on department of the patient based. If the patient has obstetric cases the history that will be taken will be obstetric history and mostly different from other history like internal medicine and pediatric

In order to know to understand and learning how to writing a good perfect and best history some material and thing =s you need to be with that form examples, clerkship of specific history you want to know, and also thing like clinical area attending routine and also rating scale, but the things you need to be with like clinical attendance that will help to get experience

But this content wants to share with you a really, perfect and best history taking of obstetrics history. But also, you can download this that a best example of history taking of obstetrics history. Below after ending of this history taking.

 

INTERNAL MEDICINE HISTORY

DEMOGRAPHIC DATA

NAME: P.R.L

AGE: 46

SEX: MALE

DOB: 1970

TRIBE: POGORO

RESIDENCE: TEGETA

MARITAL STATUS: MARRIED

LEVEL OF EDUCATION: ORDINARY LEVEL

OCCUPATION: SOCIAL WORKER                                            

NEXT OF KIN: WIFE

REFERRAL: SELF REFERRAL

DATE OF ADMISSION: 4/3/2017

DATE OF CLERKSHIP: 9/3/2017

HOSPITAL DAY NUMBER: 5 DAYS POST ADMISSION.

 

 

CHIEF COMPLAINT

DIFFICULT IN BREATHING 7 Days

 

HISTORY OF PRESENT ILLNESS

This Is A 46 YearOld Man Who Is A Known Case Of Heart Failure For 3 Month On Regular Medication.

The Patient Was Apparently Well Until Seven Days Ago When He Started Gradual Onset Of Difficulty In Breathing Which Get Worse Five Days Ago Prior To Admission. It Is A Progressive Condition Occurring During The Day On Exertion And It Is Even Gets Worse At Night On Lying Flat, Sometimes It Makes A Patient To Wake Up To Seek For Air. It Is Relieved By Resting During Exertion, Sitting Upright When Wake Up And Using Two To Three Pillows When Lying On The Bed

Also, The Condition Is Associated With Easily Fatigability, Awareness Of Heartbeat, Non Productive Cough For 5 Days, Dizziness And Lower Limbs Swelling.

However, There Were No Chest Pain, Hemoptysis, Wheezes, Fever, Night Sweat, And Weight Loss.

Before Coming To The Hospital The Patient Was On Regular Medication (He Doesn’t Remember The Kind Of Medicine) But He Stop Taking Them On Arrival To The Hospital.

Upon Admission Of The Patient The Following Were Performed.

INVESTIGATION

Serum Cholesterol, Random Blood Sugar, Serum Creatinine, CXR, ECG And Echo.

Vital: BP 145/93, SPO2 82%

MANAGEMENT

Cardiac Position

Oxygen Therapy 5L/Min, Frusemide 40mg, IV Ceftriaxone 1g OD,

 

 

REVIEW OF OTHER SYSTEM

CENTRAL NERVOUS SYSTEM

No Loss Of Consciousness

No Confusion

No Headache

No Convulsion

No Blurred Vision

No Hearing Loss

No Difficulty In Speech

 

GASTRO INTESTINAL TRACT

No Loss Of Appetite

No Difficulty In Swallowing

No Painful Swallowing

No Vomiting

No Nausea

No Loss Of Weight

No Rectal Bleeding

No Diarrhea

 

GENITOURINARY SYSTEMS

No Painful Urination

No Frequency Urination

No Dysuria

No Supra Pubic Pain

No Urethral Discharge

No Hematuria

 

 

PAST MEDICAL HISTORY

PAST 2 ADMISSION

The Patient Was Admitted At Kairuki Hospital On 3/01/2017 (2 Month Ago) Due To Heart  Failure And He Was Given Treatment On Which He Claimed To Have Resolved The Symptoms He Had Presented With, He Was Discharged With Medication On Which He Cannot Remember.

He Had A History Of Admission Due To Complicated Malaria And UTI In 2014 At Muhimbili National Hospital.

He Had No History Of Surgery,

He Has No History Of Blood Transfusion,

He Has No History Of Food Or Drug Allergy

He Has No History Of Chronic Illness A Part From Heart Failure

 

 

FAMILY AND SOCIAL HISTORY

FAMILY HISTORY

The Patient Is The First Born Among 8 Siblings

Family Is Made Up Of 3 Male, 5 Male Who Are Still Alive.

There Is No Any History Of Chronic Illness Or Sudden Death In The Family

The Patient Is Married Having Single Wife And 3 Children, 2 Are Boys And One Is A Girl, 14 Yrs Old, 8yrs Old, And 3 Yrs Old Respectively.

SOCIAL HISTORY

Patient Had A History Of Smoking For About 15 Years, 5 To 8 Sticks Of Cigarette, But Stopped 2 Years Ago Due To Advice From Family And Influence From Church Members.

Also Patient Has History Of Alcohol Consumption For 19 Years, He Consumed 4 To 6 Bottles On Weekdays But During The Weekend He Could Take Up 10 Bottles Of Beer, But He Had Stop Taking Alcohol Due To The Current Health Problem.

 

NUTRITION HISTORY

The Patient Explain That He Takes Three Meals Per Day

Breakfast: Tea, Porridge, Bread, Burns, Chapatti

Lunch: Ugali, Meat, Bean, Fish, And Little Amount Of Vegetable.

Dinner: Rice, Meat, Ugali, Beans, Fish.

Patient Claimed That He Rarely Take Fruits, As Well As Taking High Salt And Fat Dietary.

Water Consumption Is About 2 To 3 Liters Per Day.

COMMENT: The Food Is Adequate In Quantity But Not In Quality Since He Takes Little Amount Of Vegetable And Fruits.

 

 

SUMMARY 1

PRL 46 Years Old Male Who Presents With The Complain Of Difficulty In Breathing For 1 Week Accompanied With Easily Fatigability, Awareness Of Heartbeat , Cough, Dizziness As Well As  Lower Limbs Swelling  For 5 Day

 

 

 

IMPRESSIONS

·         Congestive Heart Failure

·         Pulmonary Embolism

·         Pneumonia

·         Right Heart Failure

·         Cardiomyopathy



PHYSICAL EXAMINATION

VITAL SIGNS:

·         TEMPERATURE: 36.4 C (Axillary Temperature)

·         PULSE RATE: 120 Beat/Min

·         BLOOD PRESSURE: 148/96

·         OXYGEN SATURATION: 86%

·         RESPIRATORY: 30 Breath/Min

 

 

GENERAL EXAMINATION

Head: Normal Shape, Normal Colour, Good Texture, Evenly Distributed Not Easily Plucked Off

Ears: No Lesion On The Pinna, No Discharge.

Eyes: No Periorbital Edema, No Sclera Jaundice, No Conjunctival Pallor, No Discharge, No Sunken Eyes, Normal Pupil Reflex.

Nose: No Discharge, No Polyps, Normal Mucosal Membrane, No Inflammation.

Mouth: Normal Lips, No Central Cyanosis, Normal Teeth Arrangement, No Oral Thrush, No Angular Stomatitis, Normal Soft And Hard Palate.

Lymph Node: No Lymph Node Enlargement On, Submental, Sub-Mandibular, Pre And Post Auricular, Anterior And Posterior Cervical, Supraclavicular, Axillary And Inguinal Lymph Node Were Not Palpable

Upper Limbs: No Peripheral Cyanosis, No Palmar Erythema, No Janeway Lesion, No Osler’s Node, No Sphincter Hemorrhages, No Finger Clubbing No Pallor Of The Palms, Normal Capillary Refill On The Nail, No Koilonychias No Fungal Infection Of The Nail. Presence Of Cannula In Situ At The Right Hand

Lower Limbs: Presence Of Pedal, Ankle Pitting Edema, No Lesion And No Fungal Infection On The Nail.




SYSTEMIC EXAMINATION

CARDIOVASCULAR SYSTEM:

1.  Rate And Rhythm Were Symmetrical The Radial Pulse And Synchronized With Carotid Pulse.

2.  Inspection: No Cyanosis, No Finger Clubbing, No Splinter Hemorrhage, No Lesion, No Surgical Or Traditional Scars Or Marks, There Is Precordium Hyperactivity.

3.  Palpation: No Tenderness, Apex Beat Felt On Left Fifth Intercostal Midclavicular Space

4.  Auscultation: S1 And S2 Were Heard, There Is No Any Added Sound

 

 

RESPIRATORY SYSTEM:

1.  Inspection: Bilateral Symmetrical Chest, Bilateral Symmetrical Chest Movement With Respiration, No Use Of Accessory Muscle, No Chest Deformity, No Therapeutic Or Surgical Scars.

2.  Palpation: Trachea Centrally Located, Symmetrical Chest Expansion, No Palpable Mass, No Tenderness, Decreased Tactile Vocal Fremitus.

3.  Percussion: Resonant Percussion Note Without Dullness.

4.  Auscultation: Crackles Heard On The Right And Left Lower Lungs Posteriorly.

 

 

PER ABDOMEN:

1.  Inspection: Symmetrical Shaped,No Distention, Normal Abdominal Wall Movement With Respiration, Inverted Umbilicus, No Tradition Or Surgical Scars.

2.  Palpation: No Tenderness, No Superficial Mass On Superficial Palpation, No Organomegaly, Tenderness Or Deep Mass On Deep Palpation.

3.  Percussion: Normal Tympanic Note.

4.  Auscultation: Normal Bowel Sound Heard.


SUMMARY 2

PRL 46 Years Old Male Who Presented With The Complain Of Difficulty In Breathing For 1 Week Accompanied With Easily Fatigability, Awareness Of Heartbeat, Cough, Dizziness And Lower Limbs Swelling Both For 1 Week, Who Is Afebrile, Tachycardic, Tachypneic, High Blood Pressure And Lower Than Expected Oxygen Saturation. On Examination He Is Not Wasted Has Precordium Hyperactivity, Reduced Breath Sound And Has Positive Findings On Auscultation Of Crackles At The Base Of The Lungs Bilaterally.

 

 

PROVISIONAL DIAGNOSIS

Congestive Heart Failure:(Due To Dyspnea, Orthopnea, PND, Cough, Awareness Of Heartbeat, Easily Fatigability, Lower Limbs Edema, Precordium Hyperactivity And Crackles At The Base Of The Lungs (Pulmonary Edema)

 

 

DIFFERENTIALS DIAGNOSIS:

·         Bacterial Pneumonia (Due To Cough, Weakness, Crackles, Would Expect Fever But Not Present)

·         Pulmonary Embolism (Due To Cough, Lower Than Expected Oxygen Saturation, But No Chest Pain)

·         Right Heart Failure (On Exam No Raised JVP, Negative Hepatojugular Reflux)

·         Cardiomyopathy (No History Of Heart Attack, No History Of Sudden Death In The Family, Sero Status Is Negative)




INVESTIGATION

·         Full Blood Picture (FBP)

·         Lipid Profile Test

·         Renal Function Test

·         Chest X-Ray

·         Electrocardiography (ECG)

·         Echocardiogram (ECHO)

 

 

MANAGEMENT

·         Diuretics To Reduce Volume In The Extra Vascular Compartment (Incase Preload And Edema)

·         Furosemide 40 Mg PO OD

·         ACE Inhibitor: Eg Captopril 6.25mg Tds To Improve Symptom

·         OR

·         Beta-Blockers:  Moderate To Severe CCF

·         Metoprolol 12.5mg OD

·         Or Carvedilol 3.125mg OD

 

 

COUNSELLING:

·         Control Hypertension

·         Avoid Dietary Fat

·         Reduce Amount Of Salt Intake In The Food

·         Encourage Compliance To Treatment.

 

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