Sana’a University

Faculty of Medicine & Health Sciences

Division of Medicine
Batch 33

Smart Sheet
for
History Taking
in
Surgery
Done by: Aiman Al-Sharabi
Batch Representative: Mohammed Al-Nuihi

May, 2021
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done with great love

َ‫لَكََأَيَــــــهَاَالجَمَيــــــل‬
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 *** Smart Sheet for History Taking in Surgery ***

Source of Information: ........................, Date: ........................, Starting-time: ...................., Completing-time: ...................

• PERSONAL HISTORY (SNAROMS ± MHR)
Sex: …………, Name: …………………………………………………, Age: …………, Residence: ……………………, Occupation: …………………,
Marital Status: …………………………….; for ……………… years; with ………………… children; the youngest is ……………… years old,
Special Habits of Medical Importance:
□ Chewing Qat □ Intaking Shammah □ Using Firewood or Charcoal (Fuelwood Consumption) □ Others: ……………………...
□ Smoking Tobacco:
- Type (□ active smoking □ passive smoking)
- Form (□ cigarettes □ shisha □ mada’a □ cigar □ pipe □ chewed □ others: …………………………………………………………..)
- Index = number of cigarettes per day …… X duration in years …… (□ mild < 100 □ moderate 100-400 □ heavy > 400)
- Cessation/Stoppage (when: ……………………………………, why: ………………………………………)
□ Drinking Alcohol: type (□ bear 250mL □ wine 100mL □ whisky 30mL □ others: ……………), amount per week: ………………
± Menstrual History:
- Her menarche was at …………… years old. She is menopausal for: ………………………………………
- Her first day of the last menstrual period (LMP) was on: ……………………………………… (to consider pregnancy)
- Her menses are (□ regular □ irregular), of (□ scanty □ average □ excessive) amount, of ……….. duration, every ………...
- Lactation ……………………………….……, Contraception (methods: ………………………………., duration: ….………………………………)
± Handedness: ……………………………………………………, ± Related Socioeconomic History: …………………….………………………………

• CHIEF COMPLAINT
The patient is: □ complaining of: (in patient’s own words) ………………………; at ………………………..; since or for …………………..
□ post-trauma: (exact time) ……………………………………………………………… before arrival to hospital.

• HISTORY OF PRESENT ILLNESS

The condition started ………………………… ago, when the patient ………………………………………………………………………………………..
(i.e. Before …………………………, the patient was quite well. Then s/he started ….………………………………………………………………)
For analysis of any complaint, ask about its (OCD ↑ ↓ LAST):
- Onset:
1. Acute Onset (□ dramatic within seconds □ apoplectic within minutes □ sudden within hours □ rapid within days)
2. Gradual Onset (□ gradual within weeks □ gradual within months □ gradual within years)
3. Insidious Onset (slow progression without obvious symptoms at first) (the patient is not aware of it developing)
- Course: □ progressive □ regressive □ stationary
& Pattern: □ intermittent/episodic/paroxysmal/coming in attacks (frequency: ……………, duration of each: ……………..)
□ remittent (in between attacks, the patient is ill)
□ continuous (any change in severity: ………………………………………………………)
- Duration: ……………………………………………………………
- ↑ by: ……………………………………………………………………………… ↓ by: ………………………………………………………………………….…
(e.g. eating, fasting, respiration, rest, activity & exertion, postural variation, diurnal variation, seasonal variation,
menstrual cycle, treatment either by herbal medicines or drugs both prescribed or over-the-counter)
- Last attack: ……………………………, Associated Symptoms: ……………………………, Treatment efficacy: …………………………..
For analysis of pain, ask about its (SOCRATES):
- Site: ………………………………….………………………… (□ Somatic pain is often well-localized □ Visceral pain is more diffuse)
- Onset: ……………………………….…………………………
- Character: □ colicky □ burning □ tingling □ stitching □ boring □ stabbing □ crushing □ tugging □ compressive
□ dragging □ heaviness □ throbbing □ sharp □ dull-aching/ill-defined □ cramp-like □ others: ………………..
- Radiation: □ localized □ radiates through local extension to ……… □ referred by a shared neuronal pathway to ………
- Associated symptoms: ……………………………….………………………………………………………….………………………………………………….
- Timing (Pattern, Course, & Duration): ……………………………….……………………………………………………………………………………..
- Exacerbating/provoking factors: ……………………………….………………, relieving factors: ……………………………….……………….
- Severity: □ mild (doesn’t interfere with work) □ moderate (interferes with work) □ severe (the patient seeks help)
(also by comparing with other common pains like toothache or by 1-10 scale if the patient is educated)
 For analysis of swelling, ask about its (OCD ↑ ↓ LAST + DN SSS):
- Discovery: ………………………………, Number: ……………………………..
- Site: …………..…………………, Side: …………………………….., Special characters: □ affecting patient's ability to work
□ reducible
□ gurgling sensation, colic, dyspepsia
□ double micturition
For analysis of ulcer or deformity, ask about its (OCD ↑ ↓ LAST + NSS):
- Number: ………………………………, Site: ………………………………, Side: ………………………………
For analysis of discharge, ask about its (OCD ↑ ↓ LAST + ACCCO):
- Amount: …………………, Content: ……………………….., Color: …………………, Consistency: …………………, Odor: …………………

1. Analysis of Chief Complaint:

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2. General Disturbance of Function & Related Symptoms:

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❖ Toxic Inflammatory Manifestations: (FAHM) □ Fever □ Anorexia □ Headache □ Malaise

❖ Metastatic Manifestations: (LBLB) (i.e. Malignancy → rapid, short duration, painless, infiltration & metastasis)
- to the Lung in the form of: □ chest pain □ dyspnea □ hemoptysis □ cough
- to the Brain in the form of: □ headache □ projectile vomiting □ blurring of vision □ sensory or motor deficits
- to the Liver in the form of: □ jaundice □ right hypochondrial pain or swelling
- to the Bone in the form of: □ bone pain or swelling □ pathological fracture

❖ General Manifestations:
- Irreducibility (□ yes □ no)
Complications - Intestinal Obstruction (□ absolute constipation □ colic □ abdominal distention □ vomiting)
of Hernia - Inflammation (□ redness □ edema □ pain □ FAHM)
- Strangulation (□ irreducible □ intestinal obstruction □ pain □ no expansile cough impulse)
- Metabolic (□ weight loss inspite of good appetite □ heat intolerance □ excessive sweating).
- Cardiovascular (□ palpitation even at rest).
- Chest (□ dyspnea).
Thyroid Toxic - Nervous (□ tremors □ irritability □ insomnia □ proximal weakness □ diplopia).
Manifestations - GIT (□ polyphagia □ diarrhea).
- Urinary (□ polyuria).
- Skeletal (□ generalized bone-ache).
- Gonadal (□ impotence in males □ menstrual disturbance in females).
Interstitial Cell - Leydig Cell Tumor Masculinization (□ precocious puberty □ extreme muscular development)
Testic. Tumors - Sertoli Cell Tumor Feminization (□ gynecomastia □ loss of Libido □ aspermia)
❖ General Etiology:
Causes Results
□ 2ry TB (2 nights → fever & sweating) (2 losses of → weight & appetite)
□ 2ry Syphilis (skin rash, genital ulcer & FAHM)
□ Infectious Mononucleosis (skin rashes & glandular fever) Generalized
□ AIDS Lymphadenopathy
□ Lymphoma (relapsing/cyclic fever, unexplained loss of weight, rash & splenomegaly)
□ Leukemia (bone-ache & bleeding tendency from body orifices)
□ 1ry TB (young, bad hygiene & cold abscess) Localized
□ Septic Focus (in the draining area) □ Malignant Focus (in the draining area) Lymphadenopathy
□ Schistosomiasis □ Hemolytic Anemia Hepatosplenomegaly
□ Malaria □ Typhoid □ Infective Endocarditis Splenomegaly
□ Chest Problems (e.g. basal pneumonia & infarction) Upper Abdominal Pain
□ Cardiac Problems → embolization Ischemia
Varicose Veins (VV) &
□ DVT (due to postphlebitic limb, prolonged recumbence, pelvic operation or mass)
Swollen Limb
□ Hemolytic Anemia □ Bed Sore □ Trauma □ TB □ Syphilis □ Metastasis □ DVT
□ Varicose Veins □ Ischemia (claudication pain) □ Lymphoma (multiple swellings) Ulcer
□ Diabetic Neuritis (numbness or loss of sensation)
□ Cardiac Problems □ Renal Problems □ Hepatic Problems Bilateral Swollen Limbs
□ Increased Intra-abdominal Pressure (abdominal or pelvic mass, ascites, COPD, etc.) Hernia or Varicocele
□ Hypernephroma □ Herniorrhaphy Varicocele
□ UTI Inguinoscrotal Swelling

❖ Common Associated Manifestations:

Congenital Mesenchymal Weakness/Defect
Salivary Gland Enlargement
Ischemia & Atherosclerosis
Various Syndromes
□ Hernia □ Visceroptosis □ 1ry Varicose Veins □ Varicocele
□ Flat Foot □ Hallux Valgus □ Kyphosis □ Piles
□ Mikulicz’s Disease (enlargement of all salivary glands, enlarged
lacrimal gland & dry mouth)
□ Sjogren’s Disease (enlarged salivary gland, enlarged lacrimal
gland, dry mouth, dry eyes, generalized arthritis)
□ Intermittent Claudication (muscle ischemia → cramp-like pain)
(Claudication Distance & Time: …………………., Rest Time: ……………)
□ Rest Pain (nerve ischemia → burning pain)
□ Angina Pectoris (heart ischemia)
□ Fainting Sensation, Syncopal Attack or TIAs (brain ischemia)
□ Pain, Hematuria or Uremia (kidney ischemia)
□ Colic or Intestinal Angina (intestine ischemia)
………………………………………………………………………………………………….…….

3. Local Disturbance of Function & Related Symptoms:

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❖ Pressure or Infiltration Manifestations of a Swelling on:
Vein □ Facial Edema □ Blackouts □ Dilated Veins on Chest Wall □ Distal Edema □ Varicose Veins
Artery □ Distal Ischemia
□ Pain □ Muscle Wasting □ Deformity □ Ulcer & Skin/Trophic Changes □ Hoarseness of Voice
□ Sensory Changes (tingling, numbness, paresthesia, hypoesthesia, anesthesia)
Nerve □ Facial Nerve Injury/Palsy (inability to close the eyes, mouth deviation, accumulation of food
between gums & cheek, or dripping of saliva from angle of mouth)
□ Horner's Syndrome (ptosis, myosis, enophthalmos, anhydrosis)
Lymphatics □ Lymphedema
Joint □ Restriction or Limitation of Joint Movement
Trachea □ Dyspnea
Esophagus □ Dysphagia
Biliary Tract □ Obstructive Jaundice
Chest □ Chest Pain □ Cough □ Dyspnea
Abdomen □ Abdominal Pain □ Back Pain □ Renal Pain

❖ Discharge:
It is an important manifestation in:
□ Breast Diseases □ Ulcers □ Chronic Sinus of a Swelling □ TB Sinus □ Syphilitic Sinus □ Parotid Gland Diseases
□ Lymphorrhea of a Swollen Limb □ Chronic Osteomyelitis □ Others: …………………………………………………………………...…

❖ Local Manifestations:
Swelling & Lymphadenopathy □ Redness
□ Hemorrhage from Minor Trauma
Varicose Veins □ Superficial Thrombophlebitis (red stricks with pain & fever)
□ Edema □ Pigmentation □ Venous Ulcer □ Dermatitis □ Eczema □ Liposclerosis
□ Thrombophlebitis (FAHM & firm tender cord-like)
Varicocele
□ Sagging Scrotal Skin (interferes with patient's activity) □ Infertility
□ Infertility □ Calcification (hard) □ Pyocele (redness, tender, fever)
Hydrocele □ Hematocele (tender, trauma or attempts for aspiration)
□ Chylocele (elephantoid fever that increases by swelling)
□ Pain □ Coldness □ Skin/Trophic Changes (loss of hair, brittle or fissured nail,
dry scaly skin, tinea pedis interdigital infection, ulceration, tapering digits)
□ Color Changes (pallor, cyanosis, redness) □ Gangrene (black discoloration)
Ischemia □ Sensory Changes (gradual paresthesia, tingling, numbness)
□ Motor Disturbance (wasting, weakness, paralysis, flexion deformity)
□ Sexual Disturbance (impotence as in Le Riche syndrome)
□ Thrombophlebitis (FAHM & lymphadenopathy as in Burger’s disease)
□ Motor Part (deformity, paralysis, wasting)
□ Sensory Part (hypoesthesia, loss of superficial or deep sensation)
Nerve Injury
□ Autonomic Part (redness of skin, loss of sweating)
□ Trophic Changes (loss of hair, brittle or fissured nail, scaly dry skin, ulcers)
- Nipple: □ Discharge □ Deviation □ Destruction
Breast Disease □ Discoloration □ Dermatitis □ Depression/Retraction
- Skin Manifestations: □ Dimpling □ Puckering □ Ulcer □ Redness □ Nodule
- Axillary LNs enlargement: □ Yes □ No
□ Recurrent Serial Attacks of Hotness, Cellulitis & Lymphangitis)
Lymphedema
□ Blebs □ Ulcers □ Heaviness & Limitation of Movement (due to the huge limb)
□ Pain □ Swelling □ Trauma □ Stiffness □ Locking □ Deformity
Joint
□ Feeling of Instability □ Restriction or Limitation of Movement
 4. Trauma:
❖ Mechanism of Injury:
The patient was exposed to: ………………………………….………………………………….………………………………….…………………………………
□ a penetrating injury in the form of:
o stab wound (object: …………………………, site: …………………………, depth: …………………………)
o gunshot (□ penetrated from the inlet at …………… to the outlet at ……………, □ stocked inside the body at ……………)
□ a blunt injury in the form of:
o direct blow by ……………
o fall from a height of …………… (in meters)
o fall-down or slipping (could be due to a CVA)
o road traffic accident (RTA): (e.g. □ hitting □ throwing away □ falling down □ sheering due to brake deceleration)
o crash between 2 hard objects: (e.g. □ car > someone standing < wall □ fallen rock > someone’s leg < ground)
□ an airstrike or a bomb explosion (either directly or nearby):
o 1ry → blast/wave trauma (may cause rupture of eardrum, contusions, dyspnea, ARDS)
o 2ry → shrapnels/splinters
o 3ry → falling objects or throwing away
o 4ry → inhalation of gases or chemicals

❖ Way of Transportation:
By whom: …………………………………., By what: …………………………………, Duration till arrival to the hospital: …………………………

❖ Symptoms & Signs:

- In the Head: □ loss of consciousness (for ……………, then became awake by ……………, then …………… happened).
- In the Neck: □ pain □ swelling □ hoarseness of voice □ laryngeal edema (may lead to airway obstruction).
- In the Extremities (UL or LL): □ pain □ swelling □ skin wound □ vessels (i.e. bleeding & stopped by ……………)
□ nerves (i.e. motor & sensory loss: ……………) □ muscles (i.e. edema & hematoma: ……………)
□ bone (i.e. deformity, fracture & protrusion: ……………).
- In the Chest: □ pain □ dyspnea □ cough □ hemoptysis (may cause pallor, anemia, hypotension).
- In the Abdomen: □ pain □ distention □ nausea □ vomiting □ constipation □ bleeding per rectum
□ wound with evisceration (may lead to bowel injury & infection).
- In the Back: □ pain (esp. its radiation due to compression of nerve roots: ……………) □ swelling □ skin wound
□ loss of motor & sensory functions of spinal cord □ loss of sphincters control

❖ Interventions:
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5.Review of Other Systems:

(there are no symptoms suggestive of other systems affection)
(other systems are irrelevant to the case)
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[1] Common Constitutional/Toxic/Non-specific Symptoms of General Health:
□ Fever □ Sweating □ Rigors □ Energy: ……………… □ Sleeping: ……………… □ Weight: ……………… □ Appetite: ………………

[2] The Cardiovascular System:

- Symptoms of Pulmonary Congestion:
□ Dyspnea: (exertional grade ………………., postural e.g. orthopnea: ………………., or time-related e.g. PND: ……………….)
□ Cough □ Hemoptysis □ Frequent/Recurrent Chest Infection
- Symptoms of Systemic Congestion:
□ LL or Sacral Edema (before ascites: ………….., pitting: …….…….., pain: ….………, side: ….………, level/extent: ….………...)
□ Ascites (after LL edema: ………………....) □ Hepatic Congestion (pain & jaundice) □ GIT Congestion (dyspepsia, etc.)
- Symptoms of Low Cardiac Output:
□ Headache, Dizziness, Lightheadedness & Syncope ± Convulsions ± Cyanosis □ Blurring of Vision □ Angina Pectoris
□ Oliguria □ Easy Fatigability & Claudication □ Pallor & Coldness of Extremities
- Symptoms of Congenital Heart Disease:
□ Cyanosis (central, peripheral or differential) □ Winter Bronchitis & Exertional Cyanosis
- Symptoms of Enlargement Pressure in Chest: □ Dysphonia (hoarseness of voice) □ Dysphagia □ Dyspnea & Cough
- Symptoms of Increased Blood Pressure (Hypertension):
□ Antihypertensive Drug Intake □ Asymptomatic Headache □ Blurring of Vision □ Tinnitus □ Epistaxis
- Symptoms of Systemic Embolization:
□ Weakness □ Chest Pain □ Painless Hematuria □ Left Hypochondrial Pain □ Blindness □ Intestinal Angina
- Other Cardiac Symptoms:
□ Chest Pain on Exertion (angina pectoris) □ Palpitation: (rhythm …………, precipitating factors …………., rate …………)
- Symptoms of Peripheral Arterial System Affection:
❖ Limb Pain:
□ LL Ischemia: 1. asymptomatic,
2. intermittent claudication with claudication distance & time ………………….., rest time: …………….,
3. night or rest pain,
4. tissue loss (e.g. ulceration or gangrene)
□ Acute Limb Ischemia (pallor, pulselessness, perishing cold, paresthesia, pain, paralysis)
□ Compartment Syndrome (severe unrelieved pain, exacerbated by movement)
❖ Abdominal Pain:
□ Mesenteric Ischemia (severe central abdominal pain after eating, significant weight loss, diarrhea)
□ AAA (asymptomatic until rupture, incidentally discovered during imaging) (abdominal/back pain or pulsation)
❖ Digital Ischemia: □ Blue Toes & Forefoot □ Raynaud’s Phenomenon (pallor → cyanosis → redness)
❖ TIA or Stroke: (focal neurological deficit of rapid onset)
- Symptoms of Peripheral Venous System Affection:
□ VV (pain, itching, swelling, ↑ by prolonged standing, eczema, hemosiderin deposition, lipodermatosclerosis, scar)
□ DVT (pain, swollen limb, cyanosed & mottled skin, venous catheter, repetitive trauma, exacerbated by activity)
□ Chronic Venous Insufficiency (distal cyanosis, varicose eczema, lipodermatosclerosis) & Ulceration (painless)
□ Superficial Thrombophlebitis (red painful area on the skin overlying the tender cord-like vein)

[3] The Respiratory System:

□ Cough: (dry or productive) (brassy/metallic, bovine/hollow, barking/hysterical, or paroxysmal) (starting site: ………..)
□ Hemoptysis:
❖ Attack (frequency …………, date …………, color …………., content …………., preceded by …………., followed by ………….)
❖ Blood (amount ………………….., content ………………….., color …………………..)
❖ Circulatory Compensation (hospitalization ………………….., blood transfusion …………………..)
❖ Dysfunction (disturbance of consciousness, bleeding from other orifices)
□ Sputum Expectoration: (Amount ……………., Content ……………., Color ……………, Consistency ……………, Odor ……………)
□ Chest Pain on Inspiration/Cough □ Cyanosis □ Dyspnea (exercise intolerance) □ Wheeze □ Stridor
□ History of Pleural Effusion Aspiration: (amount …………, color …………., clear/turbid, complicated/not, recurrent/not)
□ Symptoms of Systemic Congestion (Cor-pulmonale) □ Symptoms of Enlargement Pressure in Chest
[4] The Gastrointestinal System:
- Upper GIT Symptoms:
□ Appetite (anorexia, polyphagia, parorexia) □ Taste (ageusia, dysgeusia, cacogeusia) □ Xerostomia □ Waterbrash
□ Halitosis (acetone, stale mousy, fishy/ammoniacal, fecal, or foul dietary) □ Oral Pain & Ulcers □ Dental Problems
□ Dyspepsia:
❖ Reflux-like dyspepsia (heartburn)
❖ Ulcer-like dyspepsia (epigastric pain relieved by food or antacids)
❖ Dysmotility-like dyspepsia (nausea, eructation/belching, bloating/distension/fullness, & premature satiety)
□ Hiccough □ Dysphagia (partial/absolute, for food/drinks/both) □ Odynophagia □ Nausea □ Retching
□ Vomiting (spontaneous/induced, preceded by nausea/not, frequency: …………………….., ACCCO: ………………….………)
□ Hematemesis:
❖ Attack (frequency ………., date ………., color …………., content …………., preceded by …………., followed by ………….)
❖ Blood (amount ………………….., content ………………….., color …………………..)
❖ Circulatory Compensation (hospitalization …………………, blood transfusion ……………….., treated by ………………….)
❖ Dysfunction (disturbance of consciousness, bleeding from other orifices)
- Lower GIT Symptoms:
□ Wind/Flatulence (belching, excessive or offensive flatus, abdominal distension, borborygmi) □ Abdominal Pain
□ Abdominal Distension (fat, flatus, feces, fluid - free ascites or encysted, fetus, fibroids & solid masses, functional)
□ Ascites with History of Tapping: (amount ……………., color ……………., clear/turbid, complicated/not, recurrent/not)
□ Abd. or Groin Swelling (discovered …………, number …………, site …………, side ………., size ………., sp. charac. …………)
□ Change in Bowel Habit – Constipation/Diarrhea (frequency: ………………, ACCCO ……………….., tenesmus/dysentery)
□ Blood in Stool – Melena (black offensive shiny tarry stools) or Hematochezia (fresh bleeding per rectum)

[5] The Hepatobiliary System:

□ Jaundice □ Pale Stool □ Dark Brown (tea-like) Urine □ Pruritis/Itching □ Right Hypochondrial Pain or Mass
□ Fat Dyspepsia/Intolerance (abdominal fullness, anorexia, nausea & vomiting) □ Ascites (before LL edema)
□ Bleeding Tendency □ Gynecomastia □ Change in Libido □ Palmar Erythema □ Cachexia □ Drug Intake: ………………..

[6] The Hematological System:

□ Left Hypochondrial Pain or Mass □ LN Swelling □ Bone-ache □ Repeated Infections □ Pallor □ Easy Fatigability
□ Bleeding Tendency (petechiae, purpura, ecchymosis, epistaxis, bleeding gums, bleeding from other orifices, etc.)

[7] The Renal System:

- Upper Urinary Tract Symptoms:
□ Loin/Flank Pain □ Ipsilateral Shoulder Pain □ Fever □ Chills □ Skin Hypersensitivity □ Total Hematuria
- Lower Urinary Tract Symptoms (LUTS) or Prostatism:
a. Filling/Storage/Irritative Symptoms:
□ Dysuria (burning sens. in UTI) □ Frequency □ Urgency/Precipitancy (may → urge incontinence) □ Nocturia
b. Voiding/Obstructive Symptoms:
□ Hesitancy (difficulty starting or maintaining micturition) □ Straining to Void □ Interrupted or Poor-stream
□ Terminal Dribbling □ Sense of Incomplete Voiding □ Urine Retention (may → overflow incontinence)
c. Others:
□ Lower-abdominal/Suprapubic Pain □ Lower Back Pain □ Terminal Hematuria □ Incontinence/Enuresis
- Other Urinary Symptoms:
□ Amount/Volume (polyuria or oliguria) □ Color: …………………………………… □ Odor: ……………………………………
□ Content (frothy, pneumaturia, passage of stones, others: ………………..) □ Urethral Discharge: ………………….
□ Edema (periorbital → facial → sacral → genitalia → general: …………………………………………………………………………….)

[8] The Reproductive System:

- Male Reproductive System:
□ LUTS □ Urethral Discharge □ Infertility □ Scrotal Swelling □ Scrotal Pain □ Genitalia Itching
□ Penile Skin Lesions (phimosis, genital ulcers) □ Gynecomastia □ Loss of 2ry Sexual Hair □ Small Testes
□ Symptoms of Sexual Dysfunction (impotence & erectile dysfunction, absence of morning penile erection, reduced
or loss of libido, problems achieving orgasm, premature ejaculation, failure to ejaculate)
 - Female Reproductive System:
□ Breast (swelling, pain, atrophy, skin changes, nipple changes) □ Abnormal Vaginal Bleeding □ Vaginal Discharge
□ Amenorrhea □ Infertility □ Lower Abdominal Pain □ Pelvi-abdominal Mass □ Vulvar Mass or Genital Prolapse
□ Menstrual Disturbance □ Hot Flushes □ Urinary Symptoms (frequency, incontinence, dysuria, fistula)
□ Galactorrhea □ Genitalia Itching □ Hirsutism □ Acne □ Male-pattern Baldness □ Deepening of the Voice
□ Increased Muscle Bulk □ Clitoromegaly

[9] The Nervous System:

- Symptoms of  Intracranial Tension:
□ Bursting Unresponsive Headache □ Projectile Vomiting (at the peak of headache, not preceded by nausea)
□ Blurring of Vision ± □ Coma □ Convulsions
- Symptoms of Cranial Nerves Affection:
❖ CN1: □ anosmia □ parosmia
❖ CN2: □ visual acuity problems …………. □ visual field problems …………. □ visual color problems ………….
❖ CN3,4,6: □ ptosis □ squint □ diplopia
❖ CN5: □ sensory (facial pain, tingling, numbness, hypoesthesia, or anesthesia) □ motor (difficult mastication)
❖ CN7: □ motor (inability to close the eyes → soap enters the eyes & ↑ lacrimation, mouth deviation, dripping of
saliva from the angle of mouth, accumulation of food between gums & cheek)
□ sensory (taste problems in the anterior 2/3 of tongue)
❖ CN8: □ cochlear (tinnitus, diminished hearing, or deafness)
□ vestibular (vertigo, etc.)
❖ CN9,10,11: □ palate (nasal tone, nasal regurgitation)
□ pharynx (dysphagia, choking attacks)
□ larynx (dysphonia/hoarseness of voice, dysarthria)
□ spinal branch of CN11 (inability to turn neck laterally, shoulder drop)
❖ CN12: (tongue deviation, dysarthria)
- Symptoms of Motor Affection:
❖ Weakness:
a. Character:
1. Degree (□ paresis/weakness □ complete paralysis)
2. Tone (□ hypertonia □ hypotonia)
3. Others (□ atrophy □ fasciculations □ trophic changes e.g. hair fall & brittle nails)
b. Distribution:
1. Limb (□ upper limb □ lower limb □ both; started with …………., now …………. is affected more)
2. Side (□ unilateral; right or left □ bilateral; started with …………., now …………. is affected more)
3. Group of Muscles Affected (□ distal or proximal □ extensors or flexors □ abductors or adductors)
❖ Involuntary Movements:
a. Character:
1. Type (□ static □ kinetic)
2. Rhythm (□ regular/rhythmic □ irregular/dysrhythmic)
3. Tone (□ hypertonia □ hypotonia)
b. Distribution:
1. Limb (□ upper, lower, or both □ right, left, or bilateral □ distal or proximal)
2. Other Sites (□ head □ neck □ others: …………………..…………………………………..)
❖ Incoordination/Ataxia:
a. Cerebellar: □ LL (staggering/drunken gait)
□ UL (inability to reach the mouth with spoon properly)
b. Sensory: □ LL (unsteadiness during eye closure)
□ UL (a female cannot close back zipper of her dress, or a male cannot wear a tie without a mirror)
 - Symptoms of Sensory Affection:
❖ Superficial Sensation:
a. Character:
1. Irritative Lesion (□ pain □ paresthesia, tingling or numbness)
2. Destructive Lesion (□ hypoesthesia □ anesthesia)
b. Distribution: (□ upper, lower, or both □ right, left, or bilateral □ distal or proximal)
❖ Deep Sensation:
□ -ve/Intact (the patient feels that he walks on a solid surface)
□ +ve/Lost (the patient feels as if he walks on cotton)
❖ Cortical Sensation (stereognosis):
□ -ve/Intact (the patient can recognize things in his pocket without seeing it)
□ +ve/Lost (the patient cannot recognize things in his pocket unless he sees it)
- Symptoms of Sphincteric Control Troubles:
□ Problems in Micturition (retention, incontinence, nocturnal enuresis, hesitancy or precipitancy)
□ Problems in Defecation
- Symptoms of Sexual Troubles:
□ Impotence (partial/complete) □ Erectile Dysfunction (organic/psychogenic) □ Morning Penile Erection (weak/not)
- Other Nervous Symptoms:
□ Headache □ Dizziness □ Poor Concentration □ Irritability □ Convulsions
□ Transient Loss of Consciousness (may be due to syncopal attack, orthostatic hypotension, antihypertensive drugs,
autonomic neuropathy in DM) □ Speech Troubles □ Cerebral Affection (e.g. loss of memory, poor IQ)

[10] The Endocrine System & Metabolism:

- Symptoms of Thyroid Gland Affection:
❖ Neck Swelling or Pain.
❖ Symptoms Suggesting Hyperthyroidism:
□ fatigue □ poor sleep □ tremor □ heat intolerance □ excessive sweating □ itching □ onycholysis □ hair loss
□ irritability □ anxiety □ emotional lability □ dyspnea □ palpitation □ ankle swelling □ weight loss □ hyperphagia
□ fecal frequency □ diarrhea □ proximal muscle weakness □ oligomenorrhea □ amenorrhea
□ eye symptoms occurring in autoimmune thyroid disease (grittiness, excessive tearing, retro-orbital pain, eyelid
swelling or erythema, blurred vision, diplopia)
❖ Symptoms Suggesting Hypothyroidism:
□ fatigue □ mental slowing □ depression □ cold intolerance □ weight gain □ constipation □ dry skin or hair
□ carpal tunnel syndrome (hand pain or tingling, wasting of thenar muscles, weakness of thumb abduction)
- Symptoms of Parathyroid Gland Affection:
❖ Commonly Asymptomatic.
❖ Symptoms Suggesting Hyperparathyroidism ~ Hypercalcemia:
□ polyuria □ polydipsia □ renal stones □ peptic ulcer □ abdominal pain □ constipation
□ tender areas of bone fracture or deformity □ psychiatric symptoms (delirium, confusion)
❖ Symptoms Suggesting Hypoparathyroidism ~ Hypocalcemia:
□ post-thyroid surgery □ peripheral hyper-reflexia or tetany/muscle cramps □ perioral or peripheral paresthesia
□ autosomal dominant condition (short stature, round face, shortening of the 4th & 5th metacarpal bones)
- Symptoms of Pituitary Gland Affection:
❖ Symptoms Suggesting Pituitary Adenomas:
□ non-functioning tumors (asymptomatic, visual loss, or headache)
□ prolactinoma: - in female (galactorrhea, oligomenorrhea, amenorrhea, or infertility)
- in males (reduced libido, erectile dysfunction, and reduced 2ry sexual hair)
□ growth hormone excess: - headache & excessive sweating
- gigantism before puberty (tall stature)
- acromegaly after puberty (change in facial features, ↑ in shoe/ring/glove size)
- may be associated with (arthropathy, carpal tunnel syndrome, hypertension, DM,
colonic malignancy, or sleep apnea)
 ❖ Symptoms Suggesting Hypopituitarism:
□ headache □ vomiting □ visual impairment □ altered consciousness □ ↓ TSH □ ↓ ACTH □ ↓ FSH & LH
- Symptoms of Adrenal Gland Affection:
❖ Symptoms Suggesting Excess Exogenous or Endogenous Glucocorticoid Exposure = Cushing’s Syndrome:
□ proximal myopathy □ fragility fractures □ spontaneous bruising □ violaceous skin striae □ skin thinning
□ central obesity □ recurrent infection □ DM □ hypertension □ hypokalemia
❖ Symptoms Suggesting Inadequate Secretion of Glucocorticoid = Addison’s Disease:
□ weakness □ postural lightheadedness □ nausea □ vomiting □ diarrhea □ constipation □ abdominal pain
□ weight loss □ muscle cramps □ skin hyperpigmentation □ buccal pigmentations
❖ Symptoms Suggesting Overproduction of Mineralocorticoid = Conn’s Syndrome:
□ hypertension □ hypokalemia
❖ Symptoms Suggesting Overproduction of Catecholamines = Pheochromocytoma:
□ paroxysmal hypertension □ paroxysmal palpitations □ paroxysmal sweating
- Symptoms of Gonads Affection:
❖ Symptoms Suggesting Androgen Deficiency in Male = Hypogonadism:
□ loss of libido □ erectile dysfunction □ loss of 2ry sexual hair □ small testes □ gynecomastia
❖ Symptoms Suggesting Androgen Excess in Female = Hyperandrogenism:
□ hirsutism □ acne □ oligomenorrhea
□ virilizing tumor (male-pattern baldness, deepening of the voice, ↑ muscle bulk, clitoromegaly, hirsutism)
- Symptoms of Diabetes:
□ Polyuria & Nocturia □ Thirst □ Weight Loss □ Tiredness □ Mood Changes □ Blurred Vision
□ Bacterial & Fungal Skin Infections □ Itching of the Genitalia (pruritis vulvae in females, balanitis in males)

[11] The Visual System:

□ Altered Vision □ Double Vision (diplopia) □ Visual Loss (blindness) □ Asthenopia □ Squint □ Photophobia
□ Periorbital Edema □ Headache □ Painful Eye □ Dry Eye □ Red Eye □ Itchy Eye (burning or foreign body sensation)
□ Eye Discharge □ Watering from the Eyes (excessive lacrimation or epiphora) □ Black Spots in front of Eyes
□ Colored Halos □ Proptosis □ Ptosis □ Retraction of the Upper Eyelid □ Ectropion □ Eyelids Swellings

[12] The ENT:

- Symptoms of Ear Affection:
□ Deafness (hearing loss) □ Tinnitus □ Ear Discharge □ Headache □ Earache □ Itchy Ear □ Vertigo □ Nystagmus
□ Facial Paralysis □ Ear Swellings □ Ear Deformity □ Orbital Symptoms
- Symptoms of Nose Affection:
□ Nasal Obstruction □ Nasal Discharge □ Epistaxis □ Headache □ Nasal & Facial Pain □ Sneezing □ Snoring
□ Smell (anosmia, hyposmia, cacosmia, parosmia) □ Nasal Swellings □ Nasal Deformity □ Orbital Symptoms
- Symptoms of Throat Affection:
□ Sore Mouth □ Sore Throat □ Trismus □ Dysphonia/Hoarseness of Voice (croaky, breathy, or weak) □ Dysphagia
□ Stridor □ Choking □ Regurgitation □ Respiratory Symptoms □ Neck Swelling □ Weight Loss □ Distant Metastasis

[13] The Musculoskeletal System:

□ Bone-ache □ Myalgia □ Arthralgia □ Joint Swelling, Redness, or Hotness □ Stiffness & Restriction of Movement
□ Deformity □ Weakness & Myopathy

[14] The Skin, Hair, & Nails:

□ Skin Rash (scaly, blistering, or itchy) □ Skin Swelling or Pain □ Skin Lesion (e.g. acne, eczema) □ Skin Itching
□ Skin Dryness □ Skin Discoloration □ Hair Changes (loss, hypertrichosis, or hirsutism) □ Nail Changes

[15] The Symptoms of Psychiatric Disorders:

- Symptoms of Substance Misuse & Dependence:
❖ Pressure Applied to Doctors to Prescribe the Misused Substance:
□ manipulation □ deceit □ threats □ factitious description of illness □ malingering
 ❖ Complications Arising from the Route of Administration:
a. Intravenous Injection:
1. Local (□ abscess □ cellulitis □ thrombosis)
2. Systemic (□ bacterial endocarditis □ viral hepatitis □ HIV disease/AIDS)
b. Nasal Ingestion: □ erosion of nasal septum □ epistaxis
c. Smoking: □ oral cancer □ laryngeal cancer □ lung cancer
d. Inhalation: □ burns □ chemical pneumonitis □ rashes
❖ Symptoms of Acute Intoxication:
□ emotional & behavioral disturbance □ accidents & injuries sustained in fights
□ medical problems (hypoglycemia, ketoacidosis, aspiration of vomit, respiratory depression)
❖ Withdrawal Phenomena:
□ psychological symptoms (restlessness, anxiety, panic attacks)
□ autonomic symptoms (tachycardia, sweating, pupil dilatation, nausea, vomiting)
□ delirium (agitation, Lilliputian hallucination, illusions, delusions, seizures)
❖ Consequences of Harmful Use:
a. Neurological: □ peripheral neuropathy □ cerebellar degeneration □ cerebral hemorrhage □ dementia
b. Hepatic: □ fatty change of liver □ liver cirrhosis □ liver cancer
c. Gastrointestinal: □ esophagitis □ gastritis □ pancreatitis □ esophageal cancer □ Mallory-Weiss Syndrome
□ malabsorption □ esophageal varices
d. Respiratory: □ pulmonary TB □ pneumonia
e. Skin: □ spider naevi □ palmar erythema □ Dupuytren’s contractures □ telangiectasias
f. Cardiovascular: □ cardiomyopathy □ hypertension
g. Musculoskeletal: □ myopathy □ fractures
h. Endocrine & Metabolic: □ pseudo-Cushing’s syndrome □ hypoglycemia □ gout
i. Reproductive: □ hypogonadism □ fetal alcohol syndrome □ infertility
j. Psychiatric:
□ depression □ hallucination □ blackouts
□ Wernicke’s encephalopathy (nystagmus or ophthalmoplegia with ataxia & delirium)
□ Korsakoff’s syndrome (short-term memory deficits leading to confabulation)
- Symptoms of Depressive Disorders:
❖ Psychological:
□ low/depressed mood (i.e. depression) □ reduced self-esteem □ pessimism □ guilt □ suicidal thinking
□ loss of interest □ loss of enjoyment (anhedonia)
❖ Somatic:
□ reduced appetite □ weight change □ disturbed sleep □ fatigue □ loss of libido □ bowel disturbance
□ motor retardation (slowing of activity)
- Symptoms of Maniac Disorders:
❖ Psychological:
□ high/elevated mood (i.e. mania) □ irritability □ undue optimism □ delusion of grandeur
□ over-talkativeness □ infectious joviality □ recklessness in sexual behavior □ recklessness in spending
❖ Somatic:
□ lack of appetite □ lack of sleep □ over-activity
- Symptoms of Anxiety Disorders:
❖ Psychological:
□ apprehension □ irritability □ worry □ poor concentration □ fear of impending disaster □ depersonalization
❖ Somatic:
□ palpitations □ tremor □ sweating □ diarrhea □ frequency urination □ chest pain □ dyspnea
□ initial insomnia □ fatigue □ dizziness □ headache □ avoidance of medical treatment
- Other Psychiatric Symptoms:
□ Delirium □ Delusions □ Hallucinations □ Confusion □ Self-harm □ Disturbed & Aggressive Behavior
□ Medically Unexplained Somatic Symptoms (………………………………………………………………………………………………………...)
 6.Chronic Diseases:
The patient is a known case of: □ DM □ Hypertension □ Atherosclerosis □ Heart/Renal/Liver Disease □ Others: ……………
Its management: □ Uncontrolled □ Controlled under treatment of: ……………………………………………………………………………….

7. Investigations & Treatment:

- Previous Investigations & Treatment:
The patient sought medical advice at ………………., where s/he was ………………., and investigations were done in the form
of ………………., but s/he doesn’t know the results. Or the patient had no previous management for his/her condition.
- Current Admission:
The patient is admitted to ………………., through ………………. or as referred from ………………., on ………………. at ………………..,
& investigations have been done in the form of ………………., and the results have revealed ………………., now the patient’s
condition is managed by ……………….
- Future Investigations & Treatment: The patient is waiting for ……………….……………….……………….……………….……………….……

8. General Postoperative Complications:

□ 1ry Hemorrhage (starting during surgery) (due to surgical trauma, coagulopathy, bleeding
tendency, preoperative use of anticoagulants)
□ Reactionary Hemorrhage (due to postoperative ↑ in BP, insecure ligature slips or dislodged clot)
□ Hematoma Formation (→ mild fever)
□ Tissue Damage & Necrosis at the Site of Operation (→ mild fever)
□ Surgical Trauma (e.g. facial nerve injury during total parotidectomy, impotence following prostate
surgery, recurrent laryngeal nerve injury during thyroidectomy, injury whilst under general
Immediate anesthetic and being transported & handled in the theater)
□ Basal Atelectasis or Minor Lung Collapse (due to general anesthesia) (→ slow recovery, poor color,
mild tachypnea & tachycardia, dyspnea, chest pain, cough, persistent fever)
□ ARDS (→ rapid shallow breathing, severe hypoxemia, scattered crepitation)
□ Shock (due to blood loss, acute MI, PE, or septicemia)
□ Oliguria (due to inadequate fluid replacement)
□ Acute Urinary Retention (managed by adequate analgesia, and if this failed by catheterization)
□ Blood Transfusion or Drug Reaction (→ persistent fever)

□ Pain
□ 2ry Hemorrhage (due to infection eroding a vessel wall)
□ Acute Confusion (due to dehydration, sepsis, pain, sleep disturbance, metabolic disturbance,
medication)
□ DVT (→ leg edema, tenderness & increased warmth of the calf muscles, passive dorsiflexion of the
foot, fever)
□ Aspiration Pneumonitis (→ history of vomiting & regurgitation, rapid onset dyspnea & wheezing)
□ Pneumonia & Chest Infection (→ productive cough, fever)
□ PE (due to DVT) (→ sudden dyspnea & CVS collapse, pleuritic chest pain, pleural rub, hemoptysis,
confusion)
□ Acute Kidney Injury (due to severe or prolonged hypotension caused by antibiotics, obstructive
jaundice, aortic surgery) (→ low urine output with adequate hydration)
□ UTI (→ dysuria, frequency, urgency, persistent fever)
Early
□ Biliary Infection (→ persistent fever)
□ Paralytic Ileus / Functional Intestinal Obstruction (due to analgesia or anesthesia) (→ anorexia,
nausea & vomiting)
□ Mechanical Intestinal Obstruction (due to twisted/trapped loop, fibrinous adhesions) (→ distended
abdomen & absolute constipation, i.e. not passing flatus or stools)
□ Wound Dehiscence (→ serosanguinous discharge, fever)
□ Anastomotic Leakage (→ localized abscess & fistula, delayed recovery of bowel function,
generalized peritonitis, progressive sepsis, fever)
□ Fistula Formation (→ fever)
□ Wound/Surgical Site Infection (→ localized pain, redness, pus discharge, fever)
□ Drip Site Infection or Phlebitis (→ fever)
□ Cellulitis, Abscess Formation (→ fever) or Gas Gangrene
□ Pressure Sores
 □ Mechanical Intestinal Obstruction (due to persistent fibrinous adhesions)
□ Persistent Sinus Formation (due to deep chronic abscess)
□ Recurrence of Reason for Surgery (e.g. malignancy)
Late □ Disordered Wound Healing
□ Incisional Hernia
□ Keloid Formation
□ Cosmetic Appearance

• PAST HISTORY (SMSO)

- Similar Condition (i.e. recurrence): ……………………………………………………, ……………. ago.
- Medical Condition: □ Disease: ….………….… □ Infection: …………….… □ Trauma: ……………. □ Hospitalization: …………….…….
- Surgical Operation: (name: ……......……, time: …….....……, place: …….....……, reason: …….....….…, complication: ……......……)
- Others: □ Regular Drug Intake: …………….…….……… □ Allergy: …………….….. □ Blood Transfusion □ Exposure to Irradiation

• FAMILY HISTORY (SMP)

- Similar Condition among Family Members: …………………………………………………………………………………………………………………..
- Medical Condition:
□ Diseases among 1st degree relatives (parents, siblings & children): …………….……………………………………………………………….
□ Health of household members (indicating environmental risk factors): …………….………………………………………………………..
- Parental Consanguinity: □ 1st degree (parents are cousins) □ 2nd de. (grandparents are cousins) □ 3rd de. (not related)

• SOCIOECONOMIC HISTORY (EI HSCT)

- Educational Level: □ Illiterate □ Literate □ Educated till grade: …..…………. □ Graduated with …..…………. degree.
- Income or Social Class: □ Low □ Average □ High
- House: (type: …..………………………………, suitability: …..………………………………, crowding: …..……………………. persons/rooms)
- Supply: □ Electrical: …………….………………………….……………………….. □ Water: ….………….…………….…………….………………………
- Contact: □ Animal: …………….………………………….……………………… □ Chemical: …………….…………….…………….………………………
- Travel History: (location: …..………………………….., dates: …..………………………, vaccination & prophylaxis: …..……………………)

• SUMMARY (i.e. the collection of positive findings in history)

- Personal History: ……………………………………………………………………………………………………………………………………………………………
- Complaining of: (in medical terms) ……………………………………………………………………………….; since or for …………………………..
- Associated with: ……………………………………………………………………………………………………………………………………………………….......
- A known case of: …..……………………………………………………………………………………………………………………………………………………….
- Past History: □ Negative □ Positive: …………………………………………………………………………………………………………………………….
- Family History: □ Negative □ Positive: …………………………………………………………………………………………………………………………
- Socioeconomic History: □ Negative □ Positive: ……………………………………………………………………………………………………………
- Medical Interventions: …..………………………………………………………………………………………………………………………………………………
- For examination & further investigations.

• PROVISIONAL DIAGNOSIS (i.e. the collection of positive findings in history & physical examination)
- Summary of History: …..………………………………………………………………………………………………………………………………………………….
- Summary of Physical Examination: …..……………………………………………………………………………………………………………………………
- The diagnosis is most probably: …..………………………………………………………………………………………………………………………………..
1. Cause (etiology & pathology): ……………………………………………………………………………………………………………………………………..
2. Condition of Affected System (anatomy): ……………………………………………………………………………………………………………………
3. Complications (physiology): ………………………………………………………………………………………………………………………………………..
- For further investigations.