Medical History

Patient’s Information
 Patient’s Information

Name Address Age

Sex: M F Hand HNo: Bed No:

►Marital State: ■ single, S ■ Married, M

■ Widowed, W

► Nationality:
►♂Informant:
The main symptom and its duration, as:

Abdominal pain- 24 hours

H.P.I. (History of Present Illness) =
Anamnesis
Initial symptom
mode of onset (gradual, sudden)
date of onset (month, day and year)

♂ Characteristics
P.H. (Past History)
 Do not repeat anything already mentioned in
the H.P.I.

General health
(with age at which each occurred)
Review of the systems of the body

Head: trauma, headache

Eyes: Vision, glass, pain

Ears: Deafness, pain

Teeth: Toothache
Naso Pharynx: colds, epitaxis, obstruction

C.R (cardio-respiratory system)

►Ask about:
cough
sputum
chest pain
hemoptysis
dyspnea palpitation
edema
High Blood pressure (HBP)
G.I (Gastrointestinal system)
■ Appetite
■ loss of weight
■ vomiting
■ abdominal pain
■ jaundice
■ frequency of bowel movements
■ stools (dry soft or liquid, color)
■ hemorrhoids
■ Parasites
G.U. (Genito-Urinary system)
dysuria
hematuria
pyuria
syphilis
G.U. (Genito-Urinary system)
Menstrual and obstetrical history

► age of onset of mentruation

► dysmenorrhea
► Cycle:
interval
duration
last menstrual period
Infection: leucorrhea (Leukorrea)

► Pregnant:
multipara
nullipara

► Abortion , term (premature or not)

►child living and well or not
► Age of the marriage

► Menopause (age)
Habits:
► Tabacco
alcohol opium
morphia
how long?
taking by mouth or injected
amount?
daily cost?
► Exercise
► Diet
► Sleep
Accidents or Operation
date
place
type of anesthesia
operation
Personal and social history
Birth place, native, present residence
Particular work done
Education
Financial stays
Poor or not
Dependent (family, friend)
F.H. (Family History)
► State the health of the patient’s own parent,
brother and sister

► Health of the patient’s marital partner and children

If dead (record cause of death)

Example1: brother died at 26 with cough,

expectoration and hemoptysis
Example 2: sister died in infancy, cause unknown

► Ask if there is a history of disease in the family

The Physical Examination
►♂First describe in the detail the system particularly
affected by the disease

►And supplement in describing the other systems

Avoid the use of diagnostic terms throughout the

examination
Height
Weight
Temperature
BP
Pulse
Respirations

► General appearance
General appearance:
general impression of how seriously ill patient looks.

* Development

* Nutrition

* Position (in the bed, standing, seat)

*Mental state
► Facial expression

► Skin and mucous membranes

Pallor
Jaundice
dermatologic lesions
abnormal hair distribution
Example1:
The patient is a well developed but poorly nourished
young woman, dressed and walking

No apparent discomfort, her face shows a few papules

Skin and mucous membranes are normal

Example 2:
The patient is a well built, well nourished young
man, lying in bed in a deep stupor

His eyes wander from place to place but do not fix

on any object

His breathing is noisy and slightly rapid

All the hair of the head axillae and pubic region has
been shaved
Locally (abdomen)
Contour:
symmetry respiratory movements
visible peristalsis superficial veins
striae Scars distension
umbilicus
groin areas
Example1:
Abdomen symmetrical, no visible masses, movement
with respiration limited, especially of lower half

No visible peristalsis
Example2:
Marked enlargement of the abdomen ; contour is
flattened centrally and bulging in the flanks

In the upper half of the abdomen many dilated,

tortuous veins are seen

Halfway between the umbilicus and the symphysis

pubic is a:
small round, pigmented scar
Auscultation
Percussion
Palpation
Abdomen
Liver
Gallbladder
Spleen
Kidney
Bladder
Rectum and vaginal examination
Example:
Liver
The liver is extends 3 cm, below the costal margin in
the midclavicular line:
It soft and
smooth and is not
tender
edge sharp

Liver dullness extends to the IVth interspace in the

midclavicularline
Kidneys:
Palpation
Movable
Enlarged
Tender
Costovertebral tenderness
Bladder:
palpable, tender, bladder dullness
Uterus:
position, and height
Rectum:
hemorrhoids, fistula, Fissure
►Digital examination:
sphincter tone
internal hemorrhoids
tumor, prostate
Proctoscopy
Head:
Skull:
Symmetry, tenderness
Scalp:
Scars, eruptions

Hair:
abnormal color, Number (alopecia)

Eyes:
vision, infection: conjunctivitis, cataract
exophthalmia or not
Glands and lymph
Cervical (anterior and posterior)
Pulsation
venous engorgement
lymph and gland visible or palpable
supraclavicular
axillary
inguinal and
femoral
Cardiorespiratoy system
Chest: Size and shape
Rate and depth of respirations

Percussion: normal resonance, hyperresonance,

dullness, flatness
Auscultation
Rales:
dry
sonorous
sibilant and
moist rales
Heart
Cardiac impulse: visible, palpable or not
Location of the apex (base)

Auscultation:
thrills
systolic
diastolic
Murmurs
Radial pulse: Rate (character)
Extremities
Wasting
Tremor
Varicose veins
Ulcer
edema
Ears:
Infection:
otorhea
cerumen
► otoscopic examination if possible

Mouth:
Odor of breath, mucous ulceration
Lips: herpes, fissure
Tongue: coat, tremor or not
Teeth: complete or not, infection
Skeletal system
Spine:
rigidity
tenderness

Other bones:
Pain and motion (arthritic symptoms)
Neurological System
Intellectual function
Motor function
Weakness
Incoordination
Sensory function
touch, pain, Heat, cold
Reflexes:
Sphincter control, Babinski reflex
Summary Note:
(a summary of the history and physical examination)
Tentative Diagnosis ►► Lab and imaging
examination

► after laboratory and imaging work has been

done ►► Second Summary Note

►► Revised Diagnosis
Progress Note
(record new developments in the course of the disease)►►
Include:

1) Special diagnostic or therapeutic procedures

2) Special lab and imaging finding

3) The effect of the treatment (patient’s condition)

►►Remember to do it every day or two

Even in the most chronic condition not less often than
once a week
Discharge Note
Death Note
Thanks!