BASIC CLINICAL HISTORY OF THE SYSTEMS. 

Chapter 2: Step's of History Taking 

In this chapter, i will be covering the 'basics history' that need to know for an early diagnosed be made. I will be covering few systems, that will be the basic but most impotent question that you should ask the patient. The complete of the systems, i will be covering in chapter 3, that it will be covering up the systems and psychical examination. 

1. Cardiovascular System

Breathlessness, short of breath (sob), difficult in breathing- onset, when, eg: worse on exertion, at night- may be can be PND, or ask the patients how many pillows are they using to sleep, more than 1-should be ortopnea. Ask the patient whats the relieving factors. Listen to the breath sounds, any wheeze and see the style of breathing. (will be covering in chapter 3). 

chest pain- ask when, is it the pain started suddenly or when doing some works. The types of pain-duration,severity,radiation, exacerbating factors and relieving factors,  any associated features, any diaoporesis occur. 

Palpitations- when it started,how is the feelings and if can ask the patient to tap out a rhythm. 

Ankle swelling- where,(leg or face), when, how bad it is, when it resolve, any difficult in breathing.

2. Respiratory system

Cough- productive and colour of the sputum, night sweats, 

haemoptysis- sputum with blood 

breathlessness- see whether got cyanosis.

3. Gastrointestinal system

appetite- suddenly loss in appetite, favourite food, weight-(whether increasing, steady or falling), 

dysphagia and dyspepsia

bowel habit-is it suddenly change from normal, stool colour (malena stool, pale,the smell) and consistency, the tendency to float, rectal bleeding or mixed with stool, 

any abdominal pain, any GERD feelings, 

vomiting-the food, blood and how times.

4. Genito Urinary System

urinary frequency- how many times, when usually- at night. when it started.

dysuria- any pain when want to pee or it hesitancy and dribbling

incontinence

haematuria or altered colour- smoky colour

menstrual cycle- any change from usual

impotence- erectile dysfunction

sexual orientation

5. Musculoskeletan system

mobility, any types of arthralgia, joint stiffness or swelling.

6. Central Nervous System

sense of taste and smell- sudden change of taste and smell

weakness and headache-body weakness not due to age, severe headache on and off- not because migraine or tension headache

dizzy spells, faint and falls- feeling dizziness suddenly and almost want to fainted- may be syncopal attack

numbness- sudden numbness an some area of body, continues the feeling of numbness

eyesight- sudden diplopia,vertigo

tremor or involuntary movement- tremor on hands with on and off or continuously

dysarthria and dysphasia.