1. History and Examination
It is important to take a plan for the patient’s care based on:
SOAP technique
S= Subjective i.e. History
O= Objective i.e. Examination
A= Assessment (Impression)
P= Plan
HISTORY:
1. Personal Data:Name...Age...Sex...Nationality...Marital Status(S, M, D,
W)...Occupation…Religion…Address
2. Chief Complaint: Main Complaint (s)………………………………Duration
3. History of Present Complaint (s):
Patient admitted through OPD/ER…..
Analysis of chief complaints… PAIN (Onset, Site,
Severity, Character, Nature, Radiation or Referred or Radicular, Relieving and
Aggravating Factors)
Relation of these complaints to the SYSTEM (s) affected
NOTE:
At the end of this session you should know the DIFFERENTIAL DIAGNOSIS or
at least the working diagnosis.
4. Systemic Inquiry: All systems should be inquired….Revise Questions of each
system
5. Past History: Medical……… ...Surgical……… Blood Transfusion
6. Family History: of any familial diseases which run in families
7. Obs & Gyn History: in female
8. Drug History: Name of drugs………Frequency….Dose……...Allergic
reactions to certain medicine
9. Social History: Marital and living conditions…level of
education…Habits…Smoking or drinking or drug abuse…Travel Attitudes.
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2. EXAMINATION:
GENERAL:
Brain Functions (Consciousness, Orientation, and Alertness)….Eyes (Pallor,
Jaundice)….Nose…Mouth and Floor of the mouth (Pallor, Jaundice and Cyanosis
in lips)….Neck (Masses, Lymph Nodes)……Axillae (Lymph Nodes)…..Hand
Examination…..Lower Limb Edema…Vital Signs…Height and Weight (Body Mass
Index”BMI”=Weight in Kg / (Height in Meters)2.
SYSTEMIC: Examine all systems…. CVS…. RESP.
SYSTEM….GIT….UG….CNS….MSK
LOCAL:
Inspection………….Palpation…………….Percussion………………………..Ausculta
tion
ASSESSMENT / IMPRESSION: What you think of the problem
PLAN: Action to be taken to treat the patient (Management: i.e. Investigations
and Treatment)
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