MEDICINE HISTORY
1-PERSONAL DATA: -Name -Age -Sex -Nationality -Date of admission (OPD – ER)
-Any known illness (Duration + Medication)
2-MAIN COMPLAINT + DURATION
3-HISTORY OF PRESENTING ILLNESS (HPI): (check the note)
-Complaint analysis (e.g. Pain analysis {SSDN OOPPERRA}: Site – Severity – Duration - Nature
On & Off/Continues - Onset - Progression – End – Radiation – Precipitating, Relieving
& Aggravating Fs)
-Associated symptoms
-Previous episodes
-Review of related system
-Risk factors
-Special questions related to the differential diagnosis / Important negatives
-History of any chronic disease (check the note)
4-HOSPITAL COURSE:
-What happened since admission: Improving / Worsening
-Investigations done + Findings
-Medications given
-New diagnosis
-New complaints
-Plan (or reason for hospital stay)
5-SYSTEMIC REVIEW:
-CVS: Chest pain – Dyspnoea – Orthopnea – PND - Easy fatigability - Cold extremities
Syncope - Intermittent claudication - Palpitation – Ankle swelling – cyanosis
-Respiratory: Cough – Sputum – Heamoptysis – Sore throat – Hoarseness - Wheeze – Fever
Night sweat – Chest pain – Dysponea
-GIT: Appetite – Weight change – Nausea – Vomiting - Heamatemesis - Heart burn
Regurgitation - Dysphagia – Odynophagia – Fever - Abdominal pain - Distention
Change in bowel habits – Hematochezia - Melena – Incontinence – Jaundice
Pruritis - Dark urine – Pale stool
-Urinary: Loin pain – Dysuria – Anuria – Polyuria – Nocturia - Heamaturia - Incontinence
Urethral discharge – Urgency – Weak stream - Dribbling - Frequency
Hesitancy - Change in urine color – Retention - Incomplete emptying
-Menses: Regularity – Menorrhagia – Oligomenorrhea – Amenorrhea - Dysmenorrhea
Vaginal discharge – Genital Rash – Infertility - Breast pain – Nipple discharge
Menarche - Menopause - Pregnancies (Number + Complications)
-Endocrine: Appetite – Weight change – Sweating – Skin changes - Galactorrhea
Abnormal Pigmentation – Polyuria – Polydepsia – Polyphagia - Lethargy
Impotence – Heat or Cold intolerance – Neck swelling - Menstruation
-CNS: Headache – Back or Neck pain – Facial pain – Dizziness – Vertigo – Gait disturbance
Tremor – Numbness – Sensation loss - Limb weakness – Involuntary movements
Swallowing disturbance - Fits or convulsions – Loss of consciousness
Sphincter control - Vision/Hearing/Smell/Speech abnormalities
-Rheumatology: Joint (Pain – Swelling – Deformity – Loss of function – Weakness
Limitation of movements – Morning stiffness – Instability) - Bone pain - Myalgia
Back pain – Dry mouth or eye – Red eye - Mucosal ulcers - Raynaud’s phenomenon
Rash – Fatigue – Fever
-Dermatology: Rash – Pruritis – Skin changes – Pigmentation - Changes in hair distribution
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-Hematology: Symptoms of anemia (Dyspnoea – Fatigue – Headache – Faintness - Palpitation
Postural dizziness) – Jaundice – Bone pain - Prolonged bleeding – Easy bruising
Skin rash - Paraesthesia - Neck / Axillary / Inguinal swellings (Lymph nodes)
6-ALLERGIES
7-CURRENT MEDICATIONS: -Name -Duration -Dose -Side effects
8-PAST HISTORY:
-Medical: HTN – DM – Asthma – IHD – RA – TB – CVA – MI - Hyperlipidemia – Other
-Surgical: -Previous surgeries
-Previous procedures (e.g. Endoscopy)
-Blood transfusion: When – Times - Units – Complications – Packed RBCs/Platelets/FFP . . .
9-SOCIAL HISTORY: Marital status – Job & Income – Education – Home – Travel – Alcohol
Drug abuse - Smoking (Duration + Number of packs per day) - Animals contact
10-FAMILY HISTORY: Similar illness – History of cancers – HTN – DM – Asthma – IHD
CVA – MI – Hyperlipidemia – Blood diseases – Other
11-SUMMARY: -Name -Age -Sex
-Main complaint + Duration -Known illnesses
-Associated symptoms -Important findings (depend on the case)
Note:
(How to write a proper HPI)
-Put your story into a chronological sequence.
-Start from the last day in which the patient was in his/her usual state of health.
-You have to include in your story:
-Analysis of each symptom (Each symptom has its special analysis)
-Other hospital visits
-Investigations done + Findings
-Surgeries or procedures done
-Medications used
-Improvement or worsening of symptoms after medications use
-Reason of presentation this time
-Analyze any positive symptom you find in your systemic review.
(History of any chronic disease)
-Since when?
-Diagnosed in which hospital?
-What were the presenting symptoms?
-What investigations were done to confirm the diagnosis?
-Medications being used / Surgeries were done.
-Improving / Worsening with the medications.
-Medications compliance? Home monitoring of the disease? By what? What are the usual readings?
-Following up in which hospital? Who is the treating doctor?
-Chronic or persisting symptoms.
-Exacerbations of the disease (Acute attacks – Acute complications)? Precipitating factors?
-Hospital admissions / ICU admissions.
-Complications? Follow up in other clinics to treat the complications.
DONE BY:
Mohammed Gogandy
House Officer – 2007 / 2008
がんばって ください 。。。
Version - 2
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