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Chapter-03 History taking and General Examination

BOOK TITLE: Manual of Clinical and Practical Medicine

Author
1. Sainani GS
2. Sainani Rajesh G
ISBN
9789352701278
DOI
10.5005/jp/books/18069_4
Edition
2/e
Publishing Year
2018
Pages
33
Author Affiliations
1. Grant Medical College and J.J.Hospital, Mumbai, Maharashtra, India, Endocrine and Diabetes Centre, Visakhapatnam, India, Jaslok Hospital and Research Centre, Mumbai; Armed Forces (for life); Chicago Medical School and Mount Sinai Hospital, Chicago, USA; 10 Other Foreign Universities & Several Indian Universities, CSI, Jaslok Hospital and Research Centre, Mumbai, Maharashtra, India, Jaslok Hospital and Research Centre, Mumbai, Maharashtra, India; National CSI, Jaslok Hospital & Research Centre, Mumbai, Maharashtra, India; Grant Medical College & JJ Hospital, Mumbai, Maharashtra, India; National Academy of Medical Sciences, New Delhi, India, Emeritus International Advisor, Royal College of Physicians, London; Chicago Medical School and Mount Sinai Hospital, Chicago, USA, Jaslok Hospital and Research Center; Grant Medical College and JJ Hospital, Mumbai, Maharashtra, India
2. Jaslok Hospital and Research Center, Mumbai, Maharashtra, India, Jaslok Hospital and Research Centre, Bhatia Hospital, Mumbai, Maharashtra, India, Royal Melbourne Hospital, Australia; Jaslok Hospital, Sir HN Reliance Foundation Hospital and Bhatia Hospital, Mumbai; GI Physiology & Motility Laboratory, Digestive Diseases and Endoscopy Centre, Motiben Dalvi Hospital, Mumbai, Maharashtra, India
Chapter keywords
History taking, general examination, physical examination, social history, drug history, dietetic history, occupational history, respiration, temperature, blood pressure, sinus

Abstract

This chapter discusses history taking and general examination. Clinical skills are acquired continuously during the lifetime practice of clinical medicine. Learning bedside clinical medicine requires knowledge and experience. History taking includes presenting complaints, history of present illness, history of past illness, family history, personal and social history, drug history, dietetic history, and occupational history. Physical examination commences as the patient walks into the consultation room or while the patient is in bed. Even before starting history taking, decide whether the patient looks well or sick and whether he has or has not any obvious physical abnormality. Quick shuffling gait and pill-rolling tremors of Parkinson’s disease or the unsteady broad based gait of an ataxic patient should strike the physician as the patient enters the room. Physical examination includes decubitus, face, built, development and nutrition, causes of emaciation and loss of weight, water content of body, pulse, respiration, temperature, blood pressure, sinuses and nasal mucosa, mouth, neck, breasts, hands, and nails.

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