Medicine History

Patient Profile
Name: _________________________

Age: _______________________

Gender: Male/Female

Address: ____________________

Date: __________________________

MR#: _______________________

History given by:

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History taken in: OPD / IPD

Presenting Complaint:
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History of Presenting Complaint
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Review of System
G ENERAL : change in weight0, loss of appetite0, weakness0, fever0
ENDO : neck swelling0, hand tremors0, heat/cold intolerance0, sweating0, fatigue0, hair change0, skin change0, voice
change0, polydipsia0
GIT: dysphagia0, regurgitation0, flatulence0, heartburn0, nausea0, vomiting0, hematemasis0, abdominal pain0,
abdominal distention0, abnormal bowel habit0, constipation0, diarrhea0, rectal bleeding0, fecal incontinence0,
jaundice0
RESP : hemoptysis0, hoarseness0, wheezing0, chest pain0, shortness of breath0, night sweats0
CVS: dyspnea0, paroxysmal nocturnal dyspnea0, orthopnea0, cyanosis0, chest pain0, dizziness0, ankle swelling0,
palpitations0, syncope0, pain in legs on walking0
UGS : loin pain0, poor stream0, dribbling0, hesitancy0, dysuria0, urgency0, hematuria0, oligouria0, polyuria0,
incontinence0, nocturia0, bedwetting0, urine colour change0
CNS: behavioral changes0, depression0, memory loss0, anxiety0, tremor0, loss of consciousness0, fits0, muscle
weakness0, sensory disturbances 0, parasthesias0, dizziness0, change of smell0, vision0 or hearing0, headaches0,
seizures0, hyperactivity0
MSS : muscle aches0, bone pain0, joint swelling0, limitation of joint movement0, disturbance of gait0
S KIN : rash0, unusual marks0
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Past Medical History
MEDICAL: HTN, DM, IHD, epilepsy, TB, hepatitis, asthma, cancer, allergies,
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S URGICAL : trauma, blood transfusion, surgery, previous hospitalization,
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Medication History:
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Family History

HTN, DM, IHD, epilepsy, TB, hepatitis, asthma, cancer, allergies,

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Social History
Smoking, any other addictions: _________________________________
Water:
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Sanitary condition: __________________________________________ Socioeconomic class:
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Examination
GENERAL AND PHYSICAL EXAMINATION
Appearance: _________________________________________________________________________________________________
Vitals

Pulse: ______ bpm, rhythm: ________, volume: ________, character: ________, vessel wall: _________, peripheral pulses:
_________

Respiratory rate: __________ /min

Blood pressure: ______ / ______ mmHg

Temperature: _________

GCS: _________

Weight: _________ kg

Height: ____________________

BMI: _________

H ANDS: leukonychia0, koilonychia0, thenar0 or hypothenar0 atrophy, sweatiness0, splinter hemorrhages0, Oslers
nodes0, Heberdens nodes0, Bouchards nodes0, tremors0, prominent palmar creases0, blue nails0, red nails0,
clubbing0, Beaus lines0, Mees lines0, half and half nails0
S KIN : pallor0, rash0, petechiae0, bruises0, decreased capillary refill0, skin turgor0
EYES : both pupils round, regular and reactive, pallor0, jaundice0, ptosis0
FACE : jaundice0, periorbital edema0, proptosis0, drooping of mouth0
N ECK :, tracheal deviation0, goiter0, engorged neck veins0
LYMPH NODES: submental0, submandibular0, anterior cervical0, posterior cervical 0, preauricular0, postauricular0,
occipital0, supraclavicular0, axillary0, inguinal0
EXTREMITIES : ankle edema0, cyanosis0, erythema0, varicose veins0

CARDIOVASCULAR EXAMINATION
Inspection

Abnormal pigmentation, scar marks, visible veins, visible pulsations

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Palpation

Apex Beat: ________ intercostal space

Heaves, thrills

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Auscultation

S1+S2: ____________
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RESPIRATORY EXAMINATION
Inspection

Chest shape:
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Scar marks, pigmentation, visible veins, use of accessory muscles, nasal flaring

Chest movements:
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Palpation

Trachea:
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Chest wall movements:

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Chest expansion:
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Vocal fremitus:
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Percussion

Resonance: __________________________________________________________________________________________

Auscultation

Breath sounds: _______________________________________________________________________________________

ABDOMINAL EXAMINATION
Inspection

Scar marks pigmentation, abdominal distension,

visible veins

Umbilicus:
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Palpation

Hepatomegaly, splenomegaly, kidneys palpable, guarding, abdominal rigidity

Tenderness:
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Percussion

Liver span: ______________

Shifting dullness: ______________

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Auscultation

Bowel sounds: increased/decreased/normal

Renal bruit, splenic rub, aortic bruit

CNS EXAMINATION

Cranial nerves:
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Motor examination:
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Sensory Examination:
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Reflexes:
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Cerebellar function:
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OTHER EXAMINATION (_____________________________________________________________)

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Investigations
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Differential Diagnosis
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Plan/Treatment

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