Internal Streptococcus Infection!

yes will need many details


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K/C/O : [Duration is important. e.g.  HTN since 2 yrs. etc.]
B. Investigations :
Date :  Haemogram / Blood Report/ Urine Report/ CT scan/ MRI/USG Abdomen & Pelvis/ Thyroid       Function Test, etc.
 
C. Chief C/O: Write the complaints with sides & duration.
Give them separate nos. [e.g. 1] Abdominal pain(Rt. side)Since 8 days. Etc.
 
Please start with History of C/C : How complaints started?
H/o C/C : Write every complaint individually with-
·         Onset, decline, causation.
·         Side.
·         Location & Extension
·         Character of Pain.
·         Duration of Pain.
·         Sensation.
·         Modalities : Movements/ Positions/ Thermals/ Food Habits/ Seasonal/
                                      Time
¾     Concomitant.
Complain 1
 
 
2
 
 
3
 
4

5

6

7

Etc
 
D. Ask for any recurrent complaint. Ex. Fever, Cold, Coryza.
E. Past H/o : Any major illness (along with side if present) e.g. H/o Typhoid/ Malaria / Jaundice/
Fracture/ Fall/ Injury/ Accident.
And  H/o Vaccination – Hepatitis B / Dog bite Vaccination, etc.
Blood Group :
F. Family H/o
G. Physical Generals :
·         Habit : Alcohol / Drugs/ Smoking/ Tobacco, etc. (Since how many tears?)
·         Diet : Veg./ Mixed.
·         Appetite : Any alteration?
 
            Whether patient can tolerate hunger?
·         Desire : With reference to taste and not any particular food item. e.g. Sweet, Pungent, Spicy,
Sour, Fatty(Oily, ghee), Non- veg, milk, milk products, tea, coffee, Vegetables, Fruits, Ice Cream, Cold Drinks etc. is important. Also ask for any desire for indigestible food items.
·         Aversion : Main taste e.g. Sweet, Sour, Fatty, Non-veg etc. is also important.
·         Food :
·         Head :
·         Eyes :
·         Ears :
·         Nose :
·         Mouth :  any odour
·         Tongue : Dry/Moist/ Coating/ Cracked/ Fissured/ Imprints of teeth
·         Thirst  : Thirsty/ S.Q.S.I./L.Q.S.I./Thirstless.
·         Teeth : Carries of  teeth.
·         Gums : Bleeding Gums.
·         Taste : Any particular taste in mouth
·         Throat :
·         Chest :
·         Stomach/ Abdomen :
·         Bowel : Character of stool is important. Dry/ Hard/ Soft/ Loose. Color, Smell, Straining or not?  Etc.
·         Bladder:
·         Skin :
·         Chest & Back :
·         Extremities:
o   Upper Extremities:
o   Lower  Extremities :
·         Perspiration :
o   Scanty/ Profuse. On which part of the body?
o   Stain /Odour.
o   Hot/ Cold sweating.
·         Sleep :
o   Time : Daytime any sleeping habit / Night time sleep hrs.
o   Sound/ Natural
o   Refreshing/ Unrefreshing
o   Startles/ Snoring
o   Position : Whether lies on back / sides-which side ?
o   Covering
o   Bed+ Pillow
o   Talking/ Walking sleep during?
o   Eyes open / closed sleep during.
·         Dreams :
·         Female:
o   Menstrual History
i.                     Menarche
ii.                   Duration of cycle
iii.                  Color of discharge/ Any clots, etc.
iv.                 Smell
v.                   Any pain Before / During etc.
·  In General Discharges : Color/ Smell/ Quantity –scanty/ profuse etc. (very important)
H. Mind :
·                     Education :
·                     Occupation : (Working / Retired)
·                     Childhood at which place? –City/ Town
·                     Marital Status : Married / Unmarried
 
·                     Childhood :
o Family : Joint / Separate
o Financial Condition : Sound/ Poor/ Rich etc.
o About Study:
o Nature : Obstinate/ Mild/ Pampered/ Short Tempered/ Irritable.
o Desires Company or Not?
o Close to?
o Fear of/ Stage courage
o Playful/ Studious.
o Any impactful/ disturbing incidence in childhood.
o Angry when? How is it expressed ?
o Timid / Daring.
o Ambition.
 
·         After Marriage.
(Suppression injustice and relation with inlaws, Adjustment)
·   NOW :
o   Specially ask about main feelings : Anger, Sadness, Hypocrisy, Jealousy, etc. (Please, write in Rubric form)
o   Family: Joint / Separate
o   Financial Condition : Sound / Poor/ Rich etc.
o   Mild/ Short Tempered
o   Angry when ? How is it expressed?
o   Talkative/ Less talkative.
o   Jolly- Jesting/ Submissive
o   Affectionate / Reserved/ Censorious.
o   Reaction to Jesting
o   Reaction to Criticism.
o   Reaction to Reprimand
o   Reaction to Mortification
o   Any major conflicts
o   Sympathy about ?
o   Helping nature?
o   Desires Company?
o   About Cleanliness.
o   About Time Punctuality.
o   About Religiousness.
o   Reaction to Lie & Injustice.
o   Fears ? (Being alone, Dark, Water, Height, Quarrel, Exam, Robbers, Animals, Downward  Motion)
o   Sensitive (Physically & Emotionally)
o   Happy When?
o   Sad when?
o   Weeps when?
o   Consolation.
o   Hobbies?
o   About Social Activities.
o   Lazy/ Workaholic.
o   Industrious ?
o   Duty Bound?
o   Relation with others :
¾     Husband/ Wife
¾     Son / Daughter.
¾     In-laws.
¾     Friends.
¾     Colleagues, etc.
·         A/F :
o   Anxiety about what ?
           Loan, Court case, Money, Future, Health, Disease, Death, Job, Settlement, Children.
o   Any Anticipatory Anxiety
o   Death of Relatives :
               Reaction : Grief, Sad, Forsaken, Helpless, Weeping.
o   Any Insecurity
o   Perfectionism.
o   Fall/ Accident/ Injury/ Fracture/ Sprain/ Loss of fluid.
o   Overexertion.
o   Brooding.
o   Suppression of anger.
o   Any major setback in life.
Your Observation(Physical Appearance/Dressing).
Thermals :
                                    Summer                                          Winter
Bathing                        Hot / Cold /  Luke Warm              Hot / Cold /  Luke Warm
Fanning                       requires or not?                                             requires or not?
Covering                     Thick / Thin? (1 or 2,etc)                Thick / Thin? (1 or 2,etc)
 
·         Open air : desires or not
·         Require Sweater in Winter ?
·         Chills begin from which part?