Case taking:Stage of Observation

Steps in case taking

Case taking can be summarized into following stages

1.Stage of observation

When the patient enters into the consulting room the following features Should be carefully noted.

1.    Note the facial appearances and expressions of the patient- plethoric , Waxy, pale, puffy, edematous, myxoedematous,& so on

2.    Note whether the patient is anxious, angry, cruel, cunning, stupid, etc.

3.    Depressed patient has vertical furrows on the brow, turning down of the corners of the mouth, sits leaning forward, with shoulders hunched, the head inclined downwards and gaze directed to the floor. Anxious patient generally have horizontal creases on the forehead, raised eyebrows widened palpebral fissure, and dilated pupils. They usually sit upright with head erect often at the edge of the chair with hands gripping the sides and are restless.

4.    The peculiarity of gait. E.g.; ataxic, reeling, spastic, etc.

5.    Attitude-any form of rigidity, kyphosis, lordosis, parkinsonian attitude, etc

6.    Temperature and atmosphere of the room- when the patient enters the room observe whether he comes over clad or under clad, demands fanning (in winter) or off (even in hot weather) & so on

7.    Any bad odor its nature and source.

8.    Mood of the patient- depressed, worried, anxious, timid, irritable, indifferent, fastidious, comatose, delirium, and so on.