History Taking

[Adult]
Surgery + Internal Medicine

By : Hamza Akram
Medicine 119
Al-Najah National University
 Patient profile
o Name: ________________. Age _________________
o Gender: ________ Residency: ______
o Source of Info: ________ Reliability: ________
o Marital status : ________. Occubation: ________
o Date of admission : ________. Date of History: ________

Chief Complain
o Main cause that gets Patient in hospital is: ________________
o Duration : ________

History Of Presenting Illness

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 Patient profile
o Name: ________________. Age _________________
o Gender: ________ Residency: ______
o Source of Info: ________ Reliability: ________
o Marital status : ________. Occubation: ________
o Date of admission : ________. Date of History: ________

Chief Complain
o Main cause that gets Patient in hospital is: ________________
o Duration : ________

History Of Presenting Illness

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 Patient profile
o Name: ________________. Age _________________
o Gender: ________ Residency: ______
o Source of Info: ________ Reliability: ________
o Marital status : ________. Occubation: ________
o Date of admission : ________. Date of History: ________

Chief Complain
o Main cause that gets Patient in hospital is: ________________
o Duration : ________

History Of Presenting Illness

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 PMH
Disease Onset Drug

Examples :
◻HTN. ◻heart failure ◻DM. ◻stroke
◻asthma. ◻COPD. ◻ILD. ◻TB.
◻ Bowel Disease. ◻ IBD ◻ Liver Disease. ◻ Kidney Disease. ◻Nephrotic.
◻ Endocrine Disease. ◻ Cancer. ◻Rheumatology
◻Other/s : ____________________________________________

PSH
Surgery When? Indication Complication

Drug History & Allergy

Drug Dose + freq. Duration For what Compliance Complication

 ◻Drug/Food allergy : ________. S/S for this allergy : _______________

 ◻NKFDA
 Blood Transfusion History. Yes◻.(take/give) No◻
 Family History
Disease Relation Diagnosed at age

Examples :
◻Chronic diseases _______
◻Genetic diseases. ◻Haematology disease. ◻Cancers. ◻early Death
◻Same condition as peds patient
◻others ________________________
◻If u can to draw family pedigree
◻ consanguinity married.

Social History
 Smoking. Yes ◻________ pack/year. No◻
 Smoking in house. Yes◻. No◻
 Alcohol Yes◻__________ (type, amount) No◻
 Travel History. Yes ◻__________(Where + when) No◻
 Pets Yes◻________. No◻
 House ventilation ◻_________________ (well/poor)
 Socioeconomic status
 Occupation : ________
 Systemic Review

General
 Fever.: ◻ Undocumented ◻ Documented_____co
 Chills. Yes◻. No◻
 Sweating. Yes◻. No◻
 Fatigue. Yes◻. No◻
 Wight change: Yes◻. No◻

CardioVascular System
 Chest pain (SOCRATES)
o Site:
o Onset: ◻ Sudden. ◻ Gradual
o Character: ◻ Heaviness. ◻ Stabbing ◻ Burning. ◻Other: __________
o Radia on/Referral: _______
o Associated:
o Time: ◻ Con nuous ◻ Intermi ent Dura on:_____ Frequency: _____
o Exacerba ng Factors:_________. Relieving Factors:______________
o Severity:____________
 ◻Dyspnea (use some of SOCRATES) ◻Orthopnea ◻PND
 ◻Dizziness/Syncope. ◻ Palpitation
 ◻Edema. ◻ Claudication : Distance:_____

Respiratory System
 Cough: ◻Yes. ◻No
o ◻Painful ◻Painless
o ◻ Dry. ◻ Wet
o Sound:
o Time:

 Sputum: ◻Yes. ◻No

o Amount:______
o Color: __
 Hemoptysis: ◻Yes. ◻No
o Amount:_____
o Appearance: ◻ Blood-streaked. ◻ Clots
o Frequency/Duration: _____
 Wheezing ◻Yes. ◻No
 sore throat ◻Yes. ◻No
 Cyanosis ◻Yes. ◻No
 GIT System
 ◻ Dysphagia: ◻ Solids ◻ Liquid ◻ Both

◻ Intermittent ◻ Continuous

 Abdominal Pain: ◻.Yes—> Ask SOCRATES. ◻.No

 Mouth ulcers. ◻.Yes. ◻.No
 Odynophagia ◻. Yes. ◻.No
 Nausea. ◻.Yes. ◻.No
 Vomiting: ◻.Yes. ◻.No
o Amount:
o Blood? _________
o Color:
o Odor:
o ◻Preceded by nausea. ◻ Without warning
o ◻With abdominal pain ◻ Without pain
o ◻Pain relieved after vomit. ◻Not relieved
o ◻Related to meals. Yes◻. No◻
o ◻Related to times:
o ◻Projectile ◻ Non-Projectile

 Hematemesis: ◻.Yes. ◻.No

o Amount: ____
o ◻ Coffee-ground ◻ Fresh
o ◻Preceded by retching
o ◻Blood only appears after the first vomit.
o ◻Medications (NSAIDs/corticosteroids)
 Heartburn. ◻.Yes. ◻.No
o Relieved by:
o Weight loss
o Loss of appetite
 Altered bowel habit: ◻.Yes. ◻.No

o Frequency ◻ Increase. ◻ Decreased

o Consistence. ◻ Watery. ◻ Soft. ◻ Hard
o Color:
o Odor:
o Blood: ◻ Melena (Black Shiny tarry stool). ◻ Fresh
 ◻Mucus. ◻ Pus. ◻ Tenesmus
 ◻Incontinence. ◻ Urgency
 Urinary Symptoms

 Color: ______
 Volume:
 Frequency: ◻Normal ◻increase. ◻decrease
 Stream: ◻ Normal ◻ Thick. ◻Thin
 Dysuria. ◻.Yes ◻.No
 Hesitancy. ◻.Yes ◻.No
 Urgency. ◻.Yes. ◻.No
 Incontinence ◻.Yes ◻.No
 Nocturea ◻.Yes ◻.No
 Hematuria ◻.Yes ◻.No
o Initial ◻. Terminal◻. Throughout◻.
o Painful◻. Painless◻.
o With clot◻. W/O clot◻.

Nervous System
 Headache —-> ask SOCRATES.
 Photophobia. ◻.Yes. ◻.No
 Motor problems ◻.Yes. ◻.No
 Sensory problems ◻.Yes. ◻.No
 Change in personality/judgment: ◻.Yes. ◻.No
 Convulsions. ◻.Yes. ◻.No
o Type:____.
o Duration_____
 Visual changes ◻.Yes. ◻.No
 Auditory changes ◻.Yes. ◻.No
 Tinnitus. ◻.Yes. ◻.No
 Dizziness ◻.Yes. ◻.No
 MSK System
 Muscle pain ◻.Yes. ◻.No
 Joint pain. ◻.Yes. ◻.No
o ◻Exacerbated by movement (mechanical)
o ◻Relieved by movement (inflammatory)
o ◻Morning stiffness (inflammatory)
o ◻Limitation in movement
 Joint swelling ◻.Yes. ◻.No
 Deformities ◻.Yes. ◻.No

Skin
 Rash: ◻.Yes. ◻.No
o ◻Pain ◻ Redness ◻ Swelling. ◻Blanchable
 Itching. ◻.Yes. ◻.No
 Pigment changes ◻.Yes. ◻.No
 Discharge/Bleeding ◻.Yes. ◻.No
 Hair changes. ◻.Yes. ◻.No
 Nail changes. ◻.Yes. ◻.No

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 MSK System
 Muscle pain ◻.Yes. ◻.No
 Joint pain. ◻.Yes. ◻.No
o ◻Exacerbated by movement (mechanical)
o ◻Relieved by movement (inflammatory)
o ◻Morning stiffness (inflammatory)
o ◻Limitation in movement
 Joint swelling ◻.Yes. ◻.No
 Deformities ◻.Yes. ◻.No

Skin
 Rash: ◻.Yes. ◻.No
o ◻Pain ◻ Redness ◻ Swelling. ◻Blanchable
 Itching. ◻.Yes. ◻.No
 Pigment changes ◻.Yes. ◻.No
 Discharge/Bleeding ◻.Yes. ◻.No
 Hair changes. ◻.Yes. ◻.No
 Nail changes. ◻.Yes. ◻.No

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