O R Y T AK I N G I N P A TI E N T S

HIST
S P IN AL T U B E R CU LO S I S
W IT H BY RABEENASH SINGH
1. DEMOGRAPHIC DETAILS
NAME:
AGE:
GENDER:
RACE:
RELIGION:
OCCUPATION:
ADDRESS:
DATE OF ADMISSION:
DATE OF CLERKING:
 2. CHIEF COMPLAIN
(NATURE, DURATION, RECURRENT & CHRONOLOGICAL SEQUENCE IN LAYMAN TERMS)

ACUTE LOWER BACK PAIN RADIATING TO THE RIGHT LOWER LIMB OR LEFT LOWER LIMB
COUGH
WEIGHT LOSS/ANOREXIA
FEVER
NIGHT SWEATS
HEMOPTYSIS
CHEST PAIN
FATIGUE
PRESENTATION ABSCESS IN GROIN AREA, COLD ABSCESS AT LILACEOUS REGION , PUS FROM VERTEBRAL REGION
 3. HISTORY OF PRESENTING ILLNESS
GENERAL ELABORATION OF CHIEF COMPLAINT (HISTORY OF ONSET, DURATION, CURRENT STATE,
ACTION/EVENT SEQUENCE)
SPECIFIC ELABORATION OF CHIEF COMPLAINT
ONSET (WHEN, DURATION, HISTORY)
NATURE OF SYMPTOMS (PAIN, SEVERITY, BEFORE, AFTER, DURATION BE SPECIFIC)
PREDISPOSING/PRECIPITATING/AGGRAVATING FACTORS
ASSOCIATED FACTOR (+VE/-VE)
OFFSET (HOW, WHEN, DURATION)
RELIEVING FACTOR
POSSIBLE COMPLICATIONS
REVIEW OF SYSTEMS INVOLVED (MAJOR & MINOR SYSTEMS)
4. SYSTEMIC REVIEW (OTHER SYSTEMS)

TUBERCULOUS MENINGITIS
SKELETAL TB
GENITOURINARY TB
GASTROINTESTINAL TB
5. PAST MEDICAL & SURGICAL HISTORY)

SIMILAR ILLNESS, HOSPITALIZED, ANY DISEASE, RECENT BLOOD TRANSFUSIONHIV INFECTION

HISTORY OF A POSITIVE PURIFIED PROTEIN DERIVATIVE (PPD) TEST RESULT
HISTORY OF PRIOR TB TREATMENT
TB EXPOSURE
TRAVEL TO OR EMIGRATION FROM AN AREA WHERE TB IS ENDEMIC
HOMELESSNESS, SHELTER-DWELLING, INCARCERATION
6. FAMILY HISTORY

SIMILAR ILLNESS, DISEASE RUN IN FAMILY, ANALYZE AT LEAST 3 GENERATIONS, PEDIGREE, DEATH FOR
CERTAIN DISEASE A MUST
 7. PERSONAL HISTORY (EMPLOYMENT, EDUCATION, MARITAL STATUS, CHILDREN,
GENERAL AND PSYCHOLOGICAL)

8. SOCIAL HISTORY (HOME CONDITION, TRAVEL HISTORY, TOBACCO & ALCOHOL,

DIET)

9. DRUG HISTORY
THANK YOU

SOURCES ;:
HTTP://EMEDICINE.MEDSCAPE.COM/ARTICLE/230802-CLINICAL#B3
HTTPS://WWW.HINDAWI.COM/JOURNALS/CRIOR/2012/208946/