History taking and differential diagnosis

The Health History

The Comprehensive vs. Focused Health History
The Comprehensive-More Flexible
Focused Health History-Problem Oriented, Interview
Components of the adult Health History
Identifying Data
Vital Data-Age,Gender,occupation,Weight,Height,Marital status,
Source of the history-Usually patient,Family member,Friend,Medical record.
Reliability of data-ACC. Patients memory,trust,& mood.
Chief complaint-one or more symptoms causing the patients to seek care.
Presents illness-Amplifies the Chief complaint-describes the how each symptom developed
 Including patients thoughts &feeling about the illness
 Pull the relevant portion of the review of systems
 Symptoms frequently with present illness

Past history-child hood history

Adult hood history-medical,surgical,physiotherapy,psychiatric,immunizations,screening
tests,lifestyle issues and home safety
Family History
Outlines or diagrams age and health,cause of death of siblings,parients,&grandparients
Documents presence or absence of specific illness in family such as Hypertension,DM,CAD
Personal and social history .
Describes educational level,housing, Personal interests and lifestyle
Review of systems- Documents presence or absence of common symptoms related to each major
body system
Subjective & objective Data

Subjective-What the patients tells you-All history from patients

objective Data-What physio. Detect during the examination
all physical examination findings

Type of data during Assesment

Subjective Data-What the patients tells you-All history from patients

Objective Data-What physio. Detect during the examination

The SOAP Note

 Subjective – complaints, symptoms, recent history, past medical history,
medication history, allergies, social and family history, review of systems.
 Objective – vital signs, physical findings from examination, labs tests,
blood levels of drugs, medication profile.
 Assessment – critical thinking and analysis of the problem.
 Plan – actions to be taken.

Subjective Data-
Record of patient

 Out patient – Yes/No

 In Patient – Yes/No
 Medical Rehabilitation No………..
 Date of Admission…../…../….
 Date of discharge……/……/……
 Duration………
 Consultant Dr. …………………
 General Information of vital data - Name
- Age
- Gender
- Wt/Ht
- Occupation
- Address
- Phone No

Data Documentation
 Chief Complaint
 – A brief statement of why the patient is seeking care.
– 1-2 primary symptoms with their duration.
– Recorded in the patient’s own words.
– Remember, patient’s may not always have a CC: only complain
 History of present illness(OLDCQARTS)
– Onset
– Location
– Duration
– Character/Type
– Quality (sharp, dull, ache, red blood, tarry stools)
– Quantity or severity of Disease (mild, moderate, severe)
– Aggravating
– Associated symptoms (other Diseases that occur in conjunction with
the primary Disease)
– Relieving factors
– Timing, and frequency of Disease.
– Setting: when do the Disease occur?
–
 Past Medical History
– List of past problems, related or not to the CC
 Family History
– Presence or absence of illness in the immediate family (living or dead,
illnesses
 Social History
– Alcohol, tobacco, exercise, etc.

Common Sign & System with Differential Diagnosis

1.COUGH

C-chronic inflammation.1.Brochities
2.Brochetasis
3.T.B
4.Lung abcess
5.Asthma
O-obstruction of airways 1.Neoplasm
2.Foreign object
U-upper respiratory tract infection (URI)
1.Larigites
2.Tracites
 3.Epiglotites
G-gastro esophageal reflux
H-heart disease 1.MitralStenosis
2.Pulmonary stenosis
3.Left Ventricle Failure)

2. CLUBBING
C-congenital heart disease
L- lung abscess
U- ulcerative colitis
B-bronchitis-emphysema
B- Brochetasis
I-infection (T.B)
N-neoplasm of lung
G- gernal healthy people

3.HAEMOPTYSIS

H-Hemorrhagic diathesis (bleeding disorder)

A-adenoma (bronchial)
E- embolization
M-metastasis lung cancer
O-obstructive lung disease (bronchitis,brochatases,F.O)
P-pulmonary hypertension
T-Trauma,
Y-Ventricle failure
 S-Stenosis mitral
I-infection (pneumonia, T.B)
S-sepsis (lung abscess)

4.SPUTUM
S-serous, streak
P-purulent
U-unrusty
T-tenacious
U-
M-mucous

Sputum Findings
 é amount of sputum ð infection
– Thick green or brown ð pneumonia or infection
– Yellow or gray ð allergic or inflammatory response
– Hemoptysis ð tuberculosis or carcinoma
– Pink, frothy ð severe pulmonary edema

5.CYANOSIS

C- congenital heart disease

Y- Ventricle failure
A- embolism pulmonary
N- nitrites
O-obstructive lung disease (bronchitis,brochatases,F.O)
S- sulphonamides
I- insect bite
S- stenosis (MS,AS)

6. DYSPNOEA
 Cardiovascular disease
1. High out put-1.Anemia
2.Hyperthyrodism
3.A-V shunt
2. Normal out put-1.Decounding
2.Obesity
 3.Diastolic dysfunction
3. Low out put-1.CHF
2.MI
3.Constructive pericarditis

 Respiratory disease
1.Higher controller effect
- Pregnancy

-Metabolic acidosis (Diabetic

Ketoacidosis. Lactic acidosis,
Uremia )
2. Respiratory pump failure
-Obstructive lung disease (COPD)
- Restrictive lung disease (ILD)
3.Gas exchanges abnormalities
-P. Embolization
-P.Edema
-Pneumonia

 Drugs induced
-Overdose of salicylates
-Ethylene glycol poisoning
 Psychogenic

-Psychogenic hyperventilation
-Anxiety
-Panic related

 Anaphylaxis

 Other
Acute DYSPNOEA

 Acute pulmonary Edema

 pulmonary Embolization
 CVD
 ARDS
 RSD
 COPD -Acute exacerbation
 Acute Asthma
 Pneumothorax
 Metabolic acidosis (Diabetic Ketoacidosis. Lactic acidosis, Uremia )
 Psychogenic hyperventilation
 Anxiety
 Panic related
 Anaphylaxis (Laryngeal oedema )

Chronic DYSPNOEA

 CVD-CHF
 MI
 RSD- Chronic Asthma
 COPD
 Bronchial carcinoma
 ILD
 Others –Anemia
 Hyperthyroidism
 A-V shunt
 Denouncing
 Obesity