History taking in Chest and Tuberculosis

Dr. Prashant ShuklaJunior Resident

Dept of Pharmacology

Name Age Sex Chief Complaints: Breathlessness:

I. SinceII. Worse on lying down/ standing/ working/ no effect at allIII. Medications for the sameIV. Diurnal variationsV. Seasonal variationsVI. Associated skin rashVII. Associated leg painVIII. Associated chest painIX. Associated pregnancyX. Associated OCP intakeXI. Any known allergyXII. Ankle swellingXIII. Breathlessness on inspiration / expiration

Coughi. Sinceii. Severity iii. Type :

• Serous• Mucoid• Mucopurulent• Rusty

iv. Colorv. Amount vi. Expectoration( productive/ non-productive)vii. Postural variationsviii. Diurnal variationix. Seasonal variationx. Blood in sputumxi. Associated chest painxii. Sneezingxiii. Associated medications for the samexiv. Loss of appetitexv. Loss of weightxvi. Evening rise of temperaturexvii. Haematemesis

Chest painI. SinceII. Site/ sideIII. Radiation toIV. Associated perspirationV. Loss of consciousnessVI. Sense of impending doomVII. Any medications/ hospitalizationVIII.Exacerbating factorsIX. Relieving factorsX. Onset exertional/ progressive on rest/ sudden onset/ after

mealsXI. Nausea and vomitingXII. Trauma XIII.Palpitations XIV. Change with inspiration

Wheezing/ Stridor

FeverI. SinceII. GradeIII. Diurnal variationIV. Medications for the sameV. Urine discolorationVI. Associated with chills and rigorVII. Constipation/ DiarrheaVIII.Burning micturition

Epigastric painI. SinceII. HeartburnIII. Relieved/ Exacerbated on food intakeIV. Stool discolorationV. History of blood transfusionsVI. History of vomiting

a. Colorb. Contents c. Projectile/ Non-projectiled. Presence of bloode. Duration after food intake

Personal historyI. Smoking bidis/ cigarettes/ hookah/ passive smokerII. Alcohol intakeIII. Abuse of afeem/ charas/ ganja/ cocaine/ bhangIV. Vegetarian / Non-vegetarian

Professional history Medical history

I. Similar problemsII. Any reported allergyIII. Bronchial asthmaIV. Diabetes mellitusV. Myocardial infarctionVI. HypertensionVII. Tuberculosis

• Full treatment• Category• Treatment stopped since• Took medications for

VIII.Any surgeryIX. Any reported poisoning