Ward Postings

 

🩺 **MBBS History Taking Format**

1. **Patient Profile / Demographic Data**

* Name:

* Age:

* Sex:

* Marital status:

* Occupation:

* Address:

* Religion:

* Date of admission:

* Date of history taking:

* Informant and reliability of history:

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### 2. **Chief Complaints**

> (List the main complaints in chronological order with **duration**)

* Fever for 5 days

* Cough with expectoration for 3 days

* Difficulty breathing for 1 day

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### 3. **History of Present Illness**

> Detailed analysis of each symptom:

* Onset (sudden/gradual)

* Duration

* Progression (increasing/decreasing/static)

* Character (e.g., type of pain, nature of cough)

* Associated symptoms

* Aggravating/relieving factors

* Any treatment taken and response

* Chronological order if multiple complaints

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### 4. **Past History**

* Any similar complaints in the past?

* History of hospitalization/surgery

* History of chronic illnesses (e.g., diabetes, hypertension, TB, asthma)

* Medications

* Blood transfusions

* Allergies

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### 5. **Personal History**

* **Diet:** vegetarian/mixed

* **Appetite:** normal/increased/decreased

* **Bowel habits:** regular/constipation/diarrhea

* **Bladder habits:** normal/dysuria/frequency/urgency

* **Sleep:** adequate/disturbed

* **Addictions:** smoking/alcohol/tobacco/drugs – duration and quantity

* **Occupation-related exposures**

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### 6. **Family History**

* Similar illnesses in family?

* Genetic/hereditary diseases (e.g., diabetes, hypertension, asthma, epilepsy)

* Consanguinity (if pediatric case)

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### 7. **Socioeconomic History**

* Type of housing, sanitation

* Drinking water source

* Income (can be assessed using modified Kuppuswamy scale)

* Education

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### 8. **Menstrual & Obstetric History** (if female)

* Menarche:

* Cycle: (duration, flow, regularity)

* LMP:

* Menstrual abnormalities:

* Obstetric score: G P L A

* Any abortions, stillbirths

* Contraceptive use

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### 9. **Drug History**

* Any long-term medications?

* Over-the-counter or herbal remedies?

* Recent antibiotics/NSAIDs/steroids

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### 10. **Immunization History** (esp. in pediatrics)

* As per national immunization schedule

* Last vaccine taken

* COVID-19 vaccination (if relevant)

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### 11. **Systemic Review / Review of Systems**

> Helps pick up symptoms the patient may have forgotten to mention

* **General:** weight loss, appetite loss, fever, fatigue

* **CVS:** chest pain, palpitations, edema, breathlessness

* **RS:** cough, sputum, hemoptysis, wheezing

* **GIT:** nausea, vomiting, abdominal pain, jaundice

* **CNS:** headache, seizures, loss of consciousness, weakness

* **Genitourinary:** dysuria, hematuria, frequency, urgency

* **MSK:** joint pain, swelling, stiffness

* **Skin:** rashes, itching, pigmentation

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