HISTORY TAKING
HISTORY IDENTIFYING DATA
Patients name, age, race, sex; referring physician or clinic.
SOURCE AND RELIABILITY:
Name and reliability of informant (patient, old chart, relative).
HISTORY OF PRESENT ILLNESS (HPI)
Describe the course of the patients illness, including when it began, character of the symptoms; location where the symptoms began; aggravating or alleviating factors; pertinent positives and negatives, other related diseases; past illnesses or surgeries, past diagnostic testing.
PAST MEDICAL HISTORY (PMH): Past diseases, surgeries, hospitalizations; significant medical problems; history of diabetes, hypertension, peptic ulcer disease, asthma,COPD , MI
MEDICATIONS
ALLERGIES
Penicillin?
FAMILY HISTORY
Medical problems in relatives; specifically ask about problems similar to patients illness. Asthma, MI, heart failure, hypertension, CA, TB, diabetes, kidney diseases, hemophilia.
SOCIAL HISTORY
Alcohol, smoking, drug usage. Marital status and children; employment and home situations; exposure to carcinogens or environmental agents. In children include: Sleep, play habits, grade in school.
REVIEW OF SYSTEMS (ROS)
General:
Weight gain or loss, appetite loss, fever, chills, fatigue, night sweats.
Skin
Rashes, bruising, skin discolorations.
Head
Headaches, dizziness, tenderness, lumps or masses; history of seizures, head trauma.
Eyes
Visual changes, visual acuity, visual field deficits, diplopia, inflammation.
Ears
Tinnitus, vertigo, pain, discharge.
Nose
Nose bleeds, discharge, sinus diseases.
Mouth & Throat
Dental diseases, hoarseness, sore throat, pain.
Respiratory
Cough, shortness of breath, sputum (color, amount), chest pain; history of PTB; vaccination for influenza or pneumococcus. Positive Purified Protein Derivative (PPD Testing).
Cardiovascular
Chest pain, orthopnea, paroxysmal nocturnal dysonea; dyspnea on exertion, claudication, extremity edema.
Gastrointestinal
Odynophagia, dysphagia, abdominal pain, nausea, vomiting, hematemesis, diarrhea, melena, hematochezia, constipation, bloody stool, change in bowel habits, jaundice.
Genitourinary
Dysuria, frequency, hesitancy, hematuria, polyuria, discharge, impotence, testicular masses, penile discharge.
Gynecological
Gravida/para, abortions, LMP (frequency, duration), age of menarche, menopause; dysmenorrhea, contraception, vaginal bleeding; last pelvic exam and pap smear, breast masses, self-examination, mammography.
Endocrine
Polyuria, polydipsia, polyphagia, skin or hair changes, cold or heat intolerance, hormonal therapy.
Musculoskeletal
Joint pain or swelling, arthritis, myalgias.
Skin
Easy bruising, bleeding tendencies.
Lymphatics
Lymphadenopathy.
Neuropsychiatric:
Weakness, seizures, paresthesias, memory changes, emotional depression disturbances.
Patients name, age, race, sex; referring physician or clinic.
SOURCE AND RELIABILITY:
Name and reliability of informant (patient, old chart, relative).
HISTORY OF PRESENT ILLNESS (HPI)
Describe the course of the patients illness, including when it began, character of the symptoms; location where the symptoms began; aggravating or alleviating factors; pertinent positives and negatives, other related diseases; past illnesses or surgeries, past diagnostic testing.
PAST MEDICAL HISTORY (PMH): Past diseases, surgeries, hospitalizations; significant medical problems; history of diabetes, hypertension, peptic ulcer disease, asthma,
MEDICATIONS
ALLERGIES
Penicillin?
FAMILY HISTORY
Medical problems in relatives; specifically ask about problems similar to patients illness. Asthma, MI, heart failure, hypertension, CA, TB, diabetes, kidney diseases, hemophilia.
SOCIAL HISTORY
Alcohol, smoking, drug usage. Marital status and children; employment and home situations; exposure to carcinogens or environmental agents. In children include: Sleep, play habits, grade in school.
REVIEW OF SYSTEMS (ROS)
General:
Weight gain or loss, appetite loss, fever, chills, fatigue, night sweats.
Skin
Rashes, bruising, skin discolorations.
Head
Headaches, dizziness, tenderness, lumps or masses; history of seizures, head trauma.
Eyes
Visual changes, visual acuity, visual field deficits, diplopia, inflammation.
Ears
Tinnitus, vertigo, pain, discharge.
Nose
Nose bleeds, discharge, sinus diseases.
Mouth & Throat
Dental diseases, hoarseness, sore throat, pain.
Respiratory
Cough, shortness of breath, sputum (color, amount), chest pain; history of PTB; vaccination for influenza or pneumococcus. Positive Purified Protein Derivative (PPD Testing).
Cardiovascular
Chest pain, orthopnea, paroxysmal nocturnal dysonea; dyspnea on exertion, claudication, extremity edema.
Gastrointestinal
Odynophagia, dysphagia, abdominal pain, nausea, vomiting, hematemesis, diarrhea, melena, hematochezia, constipation, bloody stool, change in bowel habits, jaundice.
Genitourinary
Dysuria, frequency, hesitancy, hematuria, polyuria, discharge, impotence, testicular masses, penile discharge.
Gynecological
Gravida/para, abortions, LMP (frequency, duration), age of menarche, menopause; dysmenorrhea, contraception, vaginal bleeding; last pelvic exam and pap smear, breast masses, self-examination, mammography.
Endocrine
Polyuria, polydipsia, polyphagia, skin or hair changes, cold or heat intolerance, hormonal therapy.
Musculoskeletal
Joint pain or swelling, arthritis, myalgias.
Skin
Easy bruising, bleeding tendencies.
Lymphatics
Lymphadenopathy.
Neuropsychiatric:
Weakness, seizures, paresthesias, memory changes, emotional depression disturbances.
Health disorder like ed also should be consulted by doctors and proper medicines must be taken for its treatment.
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