Case no.

: date: 201 \ \
1- Personal data:
Name:

sex male female

Age:

Occupation:

Marital status never married

married divorced
(single)
No. of children:

Residency:

Date of
admission:
How long did he
stayed
How he was friend Doctor clinic family self Emergency
referred

2- Chief complaint and duration:

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 3- History of present illness:

Characteristics of pain (SOCRATES)

Site:
sudden\ severe

onset
stabbing \ burned \ acing (headache ) \ colicky \ distending \ itching \ constricting
Characteristic
(Nature):

Radiation

(when it has begun) (since

onset )

Duration (how long did

the pain stays)
Timing
Pattern (Episodic or
continuous)
If episodic, duration and frequency of
attacks , If continuous, any changes in
severity
sleeping \ sitting \ drugs \ others
Relieving
factors
Exacerbating Walking
factors
Severity:

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CARDIOVASCULAR HISTORY
Chest Pain
- Where is the pain ?
- When did the pain first start?
- How long does it last?
- Does the pain radiate, if so where?
- How often do you have the pain?
- How would you describe the pain - burning, pressing, stabbing, crushing, dull, aching, throbbing, sharp,
constricting?
- Does the pain occur at rest, with exertion, with stress, after eating, when moving your arms,?
- Do you have any other symptoms with the pain such as shortness of breath, palpitations, nausea, vomiting,
coughing, fever, leg pain?

Cyanosis (bluish color skin)

- Where is the bluish color skin?
- How long have you noticed it?
- Did is seem to happen suddenly or gradually?
- What type of work do you do?
- Does anyone else in your family has this condition?
- What makes the bluish skin color better or worse?
- Have you had any chest pain, cough, or bleeding associated with the bluish color skin?

Dyspnea (shortness of breath)

- How long have you been short of breath?
- Did the shortness of breath occur suddenly or gradually?
- Do you ever wake up at night feeling short of breath (paroxysmal nocturnal dyspnea)?
- How many pillows do you sleep on at night?
- How far can you walk before you become short of breath?
- Have you notice swelling in your legs associated with your shortness of breath?
- Have you had any chest pain associated with your shortness of breath?

Edema (dependent)
- Do you have swelling in your legs?
- When did you first notice the swelling?
- Did it appear suddenly or gradually?
- Is the swelling worse in the morning or evening?
- Does the swelling decrease after a night's sleep?
- Do you shortness of breath associated with the swelling?
- Have you noticed any change in your weight?
- Does elevating your feel make the swelling go down?
- Do you have pain in your legs associated with the swelling?
- Do both legs swell equally?
- Are you taking any medications, if so, which ones?

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Fainting (syncope)
- How often do you faint (or feel like you are going to faint)?
- What are you doing when you faint (or feel like you are going to faint)?
- Have you ever lost consciousness?
- Does the fainting (of feeling like you are going to faint) occur suddenly?
- In what position were you when you fainted (or felt like you were going to faint)?
- Have you noticed anything that seem to be associated with the fainting (feeling like you are going to faint), for
example, chest pain, irregular heart beat, nausea, confusion, hunger, tingling, or numbness?
- Do you have any black, tarry bowl movements after the fainting episode?
- Do you have heavy periods?

Fatigue
- How long have you felt fatigued?
- Did the fatigue come on suddenly or gradually?
- Do you feel tired all day or only in the morning and/or evening?
- Do you feel more tired at home or at work?
- Is your fatigue relieved by rest?
- When do you feel least tired?

General
- Have you ever had any problems with your heart?
- Have you ever had angina or a heart attack?
- Have you ever had a cardiac catheterization or heart surgery?
- Do you have high blood pressure?
- Have you ever been told you had a heart murmur or had rheumatic fever?
- Have you ever had phlebitis (pain) or swelling in your legs?

Irregular Heart Beat

- Do you have any problems with irregular heart beat or palpitations (when you can feel your heart beating fast or
irregular)?
- How long have you had the irregular heartbeats?
- When did you first notice the irregular heartbeats?
- How long did the irregular heartbeats last?
- What did the irregular heartbeats feel like?
- Did anything you do stop the irregular heartbeats?
- Did the irregular heartbeats stop abruptly?
- Could you count your pulse during the episode?
- Can you tap on the table what the rhythm felt like?
- Have you noticed the irregular heartbeats during exercise?
- Did you experience any sweating, flushing, or headaches with your irregular heartbeats?
- Any you taking any medications, if so, which ones?
- Has anyone ever told you that you had problems with your thyroid gland?
- Do you smoke or use any other recreational or street drugs, if so, how much and how often?
- How much caffeine do you drink a day (coffee, tea, soft drinks)?
- After the irregular heartbeats, do you need to urinate?

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Respiratory system:
Shortness of breath
- How long have you been short of breath?
- Do you normally get short of breath?
- Has it got worse recently?
- Did it come on suddenly or gradually?
- What were you doing at the time?
- Is there anything that makes it better or worse?
- How far can you walk before having to stop due to breathlessness?
- Do you get short of breath on lying flat? How many pillows do you sleep on?
- Do you ever wake up in the middle of the night feeling breathless?

Volume of sputum ( amount )

Sputum colour
- Mucoid (clear and white), yellow/green/ brown sputum suggests viral infection.
- Haemoptysis ( blood in sputum ):
 Rust-coloured sputum suggests pneumonia
 Pink-tinged sputum suggests left ventricular failure
 Dark-red sputum suggests carcinoma

Nature of sputum _
- Thin and frothy suggests left ventricular failure:
- Thick/mucoid suggests asthma
- Offensive, foul-smelling sputum suggests bronchiectasis or lung abscess

Onset of cough
- Worse in the morning suggests postnasal drip, bronchiectasis or chronic bronchitis
- If a child has a non-productive cough at night this suggests asthma

Duration of cough
- >1 week and mucopurulent sputum suggests bacterial infection
- The longer the duration the more likelyunderlying pathology is responsible:
 Cough of 3 days suggests viral infection
 Cough of 3 weeks suggests acute or chronic bronchitis
 Cough of 3 months suggests chronic bronchitis, tuberculosis or carcinoma

Wheeze
- How long have you been wheezy for?
- Do you get it all the time or only intermittently?
- Do you get short of breath?
- Is there any chest pain?
- Is it worse at night or in the morning?
- Does exercise, cold air or pollen make it worse?

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GASTROINTESTINAL HISTORY
Dysphagia (difficulty in swallowing)
- What have you found most difficult to swallow? Solids or liquids, or both?
- Where does the food stick?
- When did you first notice this?
- Do you find it is painful to swallow? (odynophagia(is pain on swallowing, often precipitated by drinking hot
liquids.)
- Is there a feeling of obstruction?
- Is food regurgitated? If so, how long after swallowing?
- Is it a burning pain just after eating?
- If there is complaint of obstruction, ask the patient to point to the level. The obstruction is usually at that level or
below.

Vomiting (Frequency & Volume)

Haematemesis (blood in vomit )

- When did it start?
- Was this of sudden onset or have there been previous smaller episodes?
- How much blood did you vomit?
- Is it fresh blood or clotted blood? Does it look like coffee grounds?

Diarrhoea
- How long have you had it for? Longer than 2 weeks?
- When was the last formed stool that you passed?
- What is the consistency of the stool?
- How often do you pass stool? How much stool do you pass?
- Do you get this regularly?
- Is there any urgency?
- Fecal Incontinence (the accidental passing of solid or liquid stool or mucus from the rectum)
Rectal bleed
- When did you first notice the bleeding?
- What colour is it? (Is it fresh blood (lower git bleeding) or dark blood (upper git bleeding)
- Where did you notice it? (on the paper, in the pan, mixed with the stool or covering the stool)
- How much blood would you estimate it to be? (thimble, cup or bowl full)
- Is it with every bowel motion?
- Have you noticed any mucus?
- Do you have pain on passing stool?
• If there is blood is it always there or just occasionally? Is it mixed in with the stool or separate and splashes
the pan? This will help indicate if the bleeding is from low down or higher up.

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What is the colour of the stool?
- Melaena is black, sticky and tarry and results from a significant high gastrointestinal bleed.
- Steatorrhoea is pale, bulky, very offensive in smell and is often frothy, floats and takes several attempts to flush
away. This indicates gastrointestinal malabsorption of fats.
Jaundice
- When did you first notice the yellow tinge to your skin and eyes?
- Have you ever had this before?
- Ask about itching or dark urine or pale stools (obstructive jaundice) and whether there is associated weight
loss, abdominal pain or fever.
- Ask about alcohol intake, recent travel abroad, use of illicit or intravenous drugs

GENITO-URINARY HISTORY
Polyuria is an abnormally large volume of urine, and is most commonly due to excessive fluid intake
Oliguria is a reduction in urine volume to <800 ml/day. It may be appropriate with a very low fluid intake, but may also
indicate loss of kidney function
Anuria is the total absence of urine production. Exclude urinary tract obstruction, which may be lower (bladder neck or
urethral obstruction
Nocturia is micturition at night (the complaint that the individual has to wake at night one or more times)

Haematuria (blood in the urine)

- What colour is your urine?
- Is it pure blood or mixed with urine?
- Are there any clots?
- Does it happen all the time when you pass water?
- How long has this happened for?
- Is it near the beginning, end or during the entire urinestream?
- Is it associated with pain or painless?

 Are you taking rifampicin? (cause discoloured urine.)

 Have you had a fever? Stinging while passing water? Smelly urine? Lower abdominal pain or loin pain?
 Do you find you go to toilet more often during the day? Or at night?

NEUROLOGICAL HISTORY
Loss of consciousness
• Was it witnessed? Try to get answers from a witness.
• When did this happen?
• Did you know you were going to lose consciousness?
• How long were you unconscious for?
• Did you hurt yourself? Did you hit your head?

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 • What were you doing at the time?
• Were you watching TV or flashing lights? Epileptic fit
• Were you coughing? Cough syncope
• Were you passing urine? Micturition syncope
• Were you turning your head? Carotid hypersensitivity
• Were you standing up? Postural hypotension
• Were you exerting yourself, e.g. climbing stairs? Cardiac valve abnormality
• Did you have a warning? Any palpitations? Arrhythmia
• Were there any visual or sensory changes? Epileptic fit
• Did you wet yourself? Did you bite your tongue? Epileptic fit
• How did you feel afterwards? Confused for a while? Epileptic
• Did you feel fine afterwards? Non-fit
• Did you feel weak or have muscle pain after coming round? Epileptic fit
• Ask any witnesses what the patient looked like when they were coming round.

Headache
• When did you first notice it?
• What were you doing before it started?
• Did you notice anything before the onset?
• How did it come on? Suddenly or gradually?
• How long has it lasted for?
• Where does it hurt?
• Have you ever had a similar one before? How often do they come on?
• How severe is it? (Grade 1–10)
• Was it the worst headache you have ever had?
• Did it feel as if someone had hit you on the head?
• Was there any vomiting?
• Any neck stiffness?
• Dislike of lights?
• Does your headache occur frequently for a few weeks then stop for months in a cycle?
• Does it start around the eye and remain on that side of the head?
• Do you notice anything that might trigger it? Cluster headaches
• Have you noticed any weakness or change in sensation? Is it worse on lying down? Do you feel sick? Have
you vomited? Raised intracranial pressure
• Have you recently stopped/started taking painkillers? Rebound headache/analgesia induced
• Have you had any sudden loss of vision

 Is the headache exacerbated by coughing, sneezing, or sudden head movements, which can increase intracranial
pressure?

Headache
 Dizziness or vertigo
 Generalized, proximal, or distal weakness
 Numbness, abnormal or loss of sensations
 Loss of consciousness, syncope, or near-syncope
 Seizures
 Tremors or involuntary movements

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Vertigo vs Dizziness
vertigo (the illusion of movement, most commonly spinning)
Vertigo is a feeling that you or your surroundings are moving when there is no actual movement. You may feel as though
you are off balance, spinning, whirling, falling, or tilting. When you have severe vertigo, you may feel very nauseated or
vomit. You may have trouble walking or standing, and you may lose your balance and fall.

Dizziness (you may feel lightheaded or lose your balance)

Lightheadedness is a feeling that you are about to faint or "pass out." Although you may feel dizzy, you do not feel as
though you or your surroundings are moving. Lightheadedness often goes away or improves when you lie down. If
lightheadedness gets worse,

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Systemic review:
General health Cardiovascular system
Chest pain on exertion (angina)
Well-being
Appetite Palpitation
Energy Pain in legs on walking
(claudication)
Mood
Ankle swelling
Sleep Palpitation
Appetite Lying flat (orthopnoea)

Breathlessness:
Weight change
At night (paroxysmal
nocturnal dyspnoea)
Respiratory system On minimal exertion –
Shortness of breath record how much
(exercise tolerance)
Cough
Wheeze
Sputum production Gastrointestinal system
(colour, amount) Mouth (oral ulcers, dental problems)
Blood in sputum Difficulty swallowing (dysphagia –
(haemoptysis) distinguish from pain on swallowing,
Chest pain (due to i.e. odynophagia)
inspiration or coughing) Nausea and vomiting
Vomiting blood (haematemesis)
Nervous system Indigestion
Heartburn
Headaches Abdominal pain
Dizziness (vertigo or Change in bowel habit
lightheaded) Change in colour of stools (pale, dark,
tarry black,
Faints
Fits
Altered sensation Musculoskeletal system
Weakness Joint pain, stiffness
Visual disturbance or swelling
Hearing problems Mobility
(deafness, tinnitus) Falls
Memory and
concentration changes Women
Headaches Last menstrual period (consider
pregnancy)
Endocrine system Timing and regularity of periods
Length of periods
Heat or cold
Abnormal bleeding
intolerance Vaginal discharge
Change in sweating Contraception
Excessive thirst If appropriate: Pain during intercourse
(polydipsia) (dyspareunia

Genitourinary system
Pain passing urine (dysuria) Other
Frequency passing urine (at Bleeding or bruising
night, nocturia) Skin rash
Blood in the urine (haematuria)
Libido
Incontinence (stress and urge)
Sexual partners – unprotected
intercourse

10 | B y F e r a n d W a l e e d
Past medical history:

Operations:

Type Year Why

Accidents or serious injuries:

Ever entered hospital before:

No. Why Duration Year

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Family history :

Social history

How much do you

smoke ??

Diet - Does your patient have any dietary restrictions?

Are you able to walk alone , on a stick , wheel chair ?
Have you travelled any were recently?
Do you have any pets?

12 | B y F e r a n d W a l e e d
Drug history:
Drugs that are used for chronic illness ( diabetes – hypertension , etc)

Drugs recently prescribed:

Drugs prescribed when he entered the hospital

Drug allergy:

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