HISTORY TAKING IN INTERNAL MEDICINE

1 Biodata : Note Start Time: at the start of History & write it down
2 Presenting Complaint (PC)
3 History of Presenting Illness (HOPI)
4 Past History Past Medical Hx Past Surgical Hx
(PH) Childhood Hx Vaccination Hx Menstrual Hx
5 Drug & Treatment History
6 Family History
7 Review of i. General Health
ii. HEENT (Head, Eye, Ear, Nose/Neck, Throat)
Systems iii. Cardiovascular System
iv. Respiratory System
v. Gastrointestinal System
vi. Genitourinary Systems
a. Urinary Symptoms…. General
b. Male …. Specific + genital symptoms

AP
c. Females…. Already asked in menstrual
vii. Nervous System

H
viii. Hematology
ix. Musculoskeletal System, CTD, Vaculitis
C
x. Skin
xi. Endocrine
EM

xii. Psychiatric
8 Personal i. Educational & Upbringing
AE

ii. Addiction: smoking, alcohol, IV Drug abuse

History iii. Sexual History (if appropriate)
iv. Travelling: out of city & abroad
.N

EAST v. Diet & Exercise

vi. Hobbies & Leisure Activities
R

9 Social i. Occupation
D

History ii. Finance

O-FAHR iii. House & Surroundings,

iv. Any pets, animals , cooking & milk

v. Relationships & Domestic

10 Personal What Investigations and treatment given during Hospital stay in
Antecedents to Emergency & indoor?
Disease Patient education about Diagnosis, nature of disease, Rx options?
11 Functional Status Ability to move, clothe, feed himself and maintain personal hygiene
12 Concerns ‫اپ کے نزدیک بیماری کے حوالے سے سب سے بڑا مسئلہ کیا ہے ؟‬

Reflect back summary‫آ پےن ےھجمہی ھچکآیھبتکاتبتا ےہ؟‬.13

‫ایک آ پ وکیئ آیسی زیچ اتبتا اچںیہ ےگ وج ھجم ےس وپےنھچ ںیم رہ یئگ وہ ؟‬

‫ ایک آ پ اک وکیئ وسآل ےہ وج آ پ وپانھچ اچےتہ وہں ؟‬.14

 1. BIODATA
Source of History: patient him/herself, relative, care taker
‫تش‬
‫ آ پ وج ھچک اتبںیئ ےگ وہ‬، ‫ ںیم آ پ ےس آ پ یک امیبری ےک قلعتم لیصفت ےس وپوھچں اگ آور رھپ آ پ اک اعمہنی رکوں اگ تا ہک آ پ یک امیبری یک خیص یک اج ےکس‬، ‫السالم مکیلع ریمآ تام ڈآرٹک ___________ ےہ‬
‫ولعمامپ یسک آور وک فرآمہ ںیہن یک اجںیئ یگ‬

Which language you can understand better? Urdu, Punjabi, Saraiki

Name: …………………………………… (call by patient name throughout)
S/O, D/O, W/O: …………………………………………………………
Age…………………………… Date of Birth …………………………
Gender: …………………………….
Religion: ……………………………
Marital Status: …………………., number of children, male, female

AP
Educational Status: ………......

H
Complete Address: …………………………………………………….
Contact Number: ……………….
Presented on (date) ……………… in OPD/ER ……………….… of
C
EM

(Hospital) …………….......
AE

2. PRESENTING COMPLAINT
.N

.............................. ‫آ پ اتپسہل سک ےلئسم یک وہج ےس آ ےئ ؟‬

....................‫آس ےلئسم ےک ساھت آ پ وک آور یھب وکیئ فیلکت یھت ؟‬
.................................‫آس ےس ےلہپ آ پ تالکل کیھٹ ےھت ؟‬
R

......................................‫یہی ہلئسم ےلہپ وت یھبک ںیہن راہ ؟‬

D

Write down in chronological order e.g.

Fever – 3months
Pain Abdomen – 2 Months
 3. HISTORY OF PRESENTING ILLNESS
 Ask risk factors/past history specially if relevant here, Describe ONLY if relevant
else tell in Past History
DM, HTN, IHD, TB, ASTHMA, HEPATITIS B, C( ‫یس‬، ‫ہییاتاسٹئیب‬، ‫ ) اکالپیال ریاقں‬, EPILEPSY ( ‫)رمیگ‬
 Make ONE paragraph for each presenting complaint
 For each PC, Describe all particulars as follows

Mnemonic SDO- ICRT-PARA

S Site ‫اہھت اگل رک اتبںیئ ےگ ڈرڈ سک ہگج رپ ےہ ؟‬
D Duration
O Onset Sudden / Gradual,

AP
What was patient doing at time of onset?
I Intensity Mild: patient ignores it
Moderate: can’t ignore BUT does not

H
interfere with daily activities

C
Severe: interferes with daily activities
V. Severe: markedly interferes with daily
EM
activities
C Character / Intermittent / continuous,
Pattern for fever Colicky, burning, stabbing , dull
AE

R Radiation
.N

T Timing Special timing? circadian variation?

with meal?
R

P Progression ‫ ڈرڈ ےلہپ ےس رتہب ےہ تا پڑھ یئگ ےہ ؟‬/ ‫فیلکت‬

A Aggravating Factors
D

R Relieving Factors
A Associated symptoms
Other mnemonics are SOCRATES, ODPARA
 Effect of disease/complain on patient’s life … office, family
 Has patient been investigated & treated for this disease? if so details?
 What explanation patients has about disease… given by doctors or found himself
(on internet)
 Ask relevant questions here instead of systemic review
 4. PAST HISTORY (PH)
‫تش‬
‫ ہی آ پ ےک رمض یک خیص آور عالج ںیم دمڈ رک سکیے ںیہ‬، ‫ںیم آ پ ےس آ پ یک زگہتش تحص ےک تارے ںیم ھچک وسآل وپانھچ اچاتہ وہں‬

Past Medical History:

 Any H/O of similar complaints in past? if yes, what treatment was taken, for
how much duration, was it cured or there was residual disability/deficit?
 Any H/O of DM, HTN, IHD, TB, ASTHMA, HEPATITS B/C, EPILEPSY
If any disease is +ve, ask symptoms as diagnosis, treatment, compliance, control,
monitoring
 Any History of admission in Hospital?
 Any H/O days off work due to disease?
 Any H/O blood transfusions? Indications? Complications?

Past Surgical History:

AP
 Any H/O of surgery in past? Diagnosis ? complications? Bleeding stopped easily?

H
 Cataract surgery?
 Any surgery done in local anesthesia?
Childhood History: C
EM
 Normal birth? Any diseases in childhood?
Vaccination History:
AE

 EPI Schedule complete? Hepatitis B? BCG Scar?

.N

MESNTRUAL HISTORY
 Date of last menstrual period (LMP) i.e. 1st day of last menstruation
R

 Age of menarche
D

 Are periods regular?

 Duration? describe e.g. 3 (duration of flow) /28(cycle length)
 Amount of blood loss
 Intermenstrual bleeding
 Has menopause occurred? At what Age?
Pregnancies:
 Record Gravida (no. of pregnancies) &
 Para (no. of birth of babies beyond 20 weeks of gestations)
 Mode of delivery
 Any complications … blood loss (Sheehan) , HTN , DM , Eclampsia
Breasts: Lumps , discharge , bleeding
 5. DRUG & TREATMENT HISTORY

1. Are you taking any medicines for current problem?

2. Are you taking any other medicines at the moment, other than
this disease?
3. Are you taking any medicine without prescription by doctor? Any
multivitamins? Pain killers?
4. Any special diet for treatment? Supplements or restriction?
5. Any courses of physiotherapy for treatment?

AP
6. Do you use OCPs? (in females of child bearing age)
7. Do you use any inhalers?

H
8. Do you use homeopathic, Hakeem medications or natural
remedies? C
EM
9. Are you allergic to any medicine? If yes, what EXACTLY was
allergic reaction?
AE

10. Any H/O Procedures e.g. radiotherapy , endoscopy etc.

.N

If taking any medicine, Ask

R

i. Name
D

ii. Dosage
iii. For how long?
iv. Indication
v. Adverse Effects
vi. Compliance
vii. Monitoring
viii. Control
 6. FAMILY HISTORY

 Anyone in family has similar complaints (as PC of this patient)?


‫ایک وکیئ آیسی امیبری ےہ وج آ پ ےک اخدنآں ںیم وہ ؟‬

 Any H/O DM, HTN, premature IHD, ASTHMA, TB, HEPATITIS B/C,
EPILEPSY specially in first degree relatives e.g. parents, siblings &
children
 Any H/O malignancy in family specially breast 7 colon
 Draw family tree if needed

AP
 Notes if the patient of any other affected member is adopted

H
C
EM
AE
.N
R
D
 7. SYSTEMIC REVIEW

1. General Health …… Mnemonic: I Sleep WAFR (‫)وآفر‬

W Weight gain or loss
Intentional or unintentional
A Appetite: ↑, ↓ or N
F Fever
R Reduced Energy(fatigue)
S Sleep:
I Itching

AP
2. HEENT (Head, Eye, Ear, Nose, Neck, Throat)
H Hair loss, texture

H
Vision?
Redness? C
EM
Dryness? ‫رڑک‬
EYE
Swelling?
Diplopia?
AE

Loss of eyebrows ‫پروٹے‬

Hearing?
.N

EAR
Ear Discharge
Nose Smell
R

Epistaxis
D

Allergy
Pain in sinuses
Difficulty in breathing/obstruction
Neck Swelling in neck, moves with
deglutition
Any lumps & bumps
Throat Pain
Mouth ulcers
Taste: Change of taste in
hepatitis, uremia
 3. CARDIOVASCULAR SYSTEM SAD-OP4D
S Syncope: At rest, at activity
A Angina
D Dyspnea
O Orthopnea
P PND
P Palpitations
P Pedal edema
P Pain in legs on walking
D DVT/PE. Past Hx

AP
4. RESPIRATORY SYSTEM F.SC Home Work Problem

H
F Foul smelling from mouth
S
C
Sputum
Cough
C
EM

H Hoarseness, hemoptysis
W Wheezing
AE

P Pleuritic chest pain

.N

5. GASTROINTESTINAL SYSTEM USAID-BJP

U Ulcers. mouth, rectal
R

S Swallowing: Difficulty, pain,

D

regurgitation
A Appetite
I Indigestions: nausea,
vomiting, Retching,
D Distension,

B Bowels: diarrhea,
Constipation Blood in stool
J Jaundice
P Pain abdomen
 6. GENITOURINARY SYSTEM BV Lost Pakistani F2UND
B Blood in urine
V Volume … ↓ AKI or ↑ DI
L Loin to groin pain
P Periorbital puffiness
F Frequency, frothy urine
U Urgency
N Nocturia
D Dysuria ... burning micturition
Males Prostatism (hesitancy, poor stream)
urethral discharge,

AP
erectile dysfunction
Testicular size , swelling

H
7. NERVOUS SYSTEM
General Headache
Neck stiffness
C
EM
Dizziness
Fits
Weakness of any part of body
AE

Numbness / paraesthesias
Frontal Memory
.N

Irrelevant talk
Parietal Reading
Writing
R

Temporal Hearing
D

Auditory hallucinations
Occipital Vision
Visual hallucinations
Cerebellum ‫ےتلچ وہےئ ڑلڑھکآےت وت ںیہن ؟‬
Post. Ataxia
column
Midbrain Diplopia , ptosis
pons Facial weakness
Medulla Change in voice, nasal regurgitation (‫)اھکتا اھکےت وہےئ وغطہوت ںیہن اتگل‬
Spinal Cord Sphincters ..incontinence
ANS Postural dizziness
 8. HEMATOLOGY BB-LAD
B Bruising
B Bleeding .. from any site Gums ,
L Lumps & bumps
A Anemia symptoms

D DVT /PE Hx
9. MUSCULOSKELETAL SYSTEM, CTD, Vasculitis JR- PEMRa
MSK ‫ وھٹپں تا رمک ںیم ڈرڈ تا آکڑآو وت ںیہن وہتا ؟‬، ‫آ پ ےک وجروں‬
‫رکیس رپ تیٹھ رک ڑھکے وہےن ںیم وکیئ ہلئسم ؟‬/ ‫ ڑیسایھں ڑچ ھیے آور وآس روم‬، ‫نٹب دنب رکےن‬
CTD/SLE ‫میہ ںیم اھچےل ؟ تال وھچگں یک وصرپ ںیم وت ںیہن رگےت ؟ ڈوھپ ںیم اجےن ےس رہچے رپ نلج وہیت وہ ؟ الل وہ‬

AP
‫اجتا وہ ؟ وجروں ںیم ڈرڈ؟ ےچین تیٹھ رک ڑھکے وہےن ںیم ہلئسم ؟‬
Vasculitis ‫مسج رپ اخض وطر رپ تاوگنں رپ وکیئ آرھبے وہےئ ڈآےن ےتنب وہں ؟ ڈو ڈو رظن وت ںیہن آ ےت ؟ وھچےٹ تیساپ ےک ساھت‬

H
‫وخں وت ںیہن آ تا ؟ مغلب ےک ساھت وخں ؟‬
10. DERMATOLOGY BRIC ‫پڑک‬
C
EM
Rash
Bruisibility
AE

Itching
Color change
.N

11. ENDOCRINOLOGY
R

Thyroid Heat/cold intolerance, altered bowel habits, sweating, palpitations

D

PTH Polyuria, Bone pain, fractures

Pancreas Polydipsia, polyuria, polyphagia, hypoglycemia
NET Diarrhea, flushing, wheezing
Adrenal Color change, postural dizziness, weight gain, hirsutism, purple striae
Pituitary Secondary sexual characters , menstrual Hx , fertility , DI
12. Psychiatric History SIG-E-CAPS Sig. Energy Capsules
Sleep , Interest deficit (anhedonia), Guilt (worthlessness), Energy deficit, Concentration
deficit, Appetite loss, Suicidal ideation …..Depression
Easily distracted ,
Repeatedly doing same task .. OCD
 8. PERSONAL HISTORY EAST
i. Educational & Upbringing:
Behavior problem?
Schooling? how much educated?

ii. Addiction:
Smoker : pack years
‫اگسر ؟ بک ےس ؟ آتک ڈں ںیم ےنتک ؟‬/ ‫ ہشیش‬/ ‫ایک آ پ ےن یھبک رگسپٹ ایپ ےہ ؟ ہقح‬

Alcohol: CAGE C: Ever tried to cut down? A: got angry as people

AP
criticized? G: ever felt guilty? E: Ever you took alcohol first thing in
morning to make you steady (Eye opener)?

H
Drugs: chars, heroin, IV Drug (needle sharing, injected where?)
iii. Travelling: out of city & abroad
C
EM

Why? Accommodation, water, eating, activities, sexual contact

AE

iv. Sexual History (if appropriate) 5P’s

P Partners Married, how many… illicit, how many, sex worker or amateur
.N

P Practices Vaginal, oral, anal … satisfied, erectile dysfunction

P Protection Condom? any other methods?
R

P Pregnancy Want to be pregnant /infertility OR Avoid pregnancy/Use OCP

D

P Past Hx Past Hx of STDs

v. Diet & Exercise
Diet : any special restriction or supplementation , do you eat too
much ? how many times per day? Do you use vegetables or
foods?
Exercise: What? duration? regular?
vi. Hobbies & Leisure Activities
 9. SOCIAL HISTORY O-FAHR
i. Occupation: WHACS
WHACS. What, How, Concern, Colleagues, satisfied?
 Current occupation, …. (What)
 what is exact job of patient in that occupation? …. (How)
 Any other occupation before current one in lifespan?
 Are you concerned about any exposure or experience at workplace?
 Are your colleagues healthy, any similar complaint in colleagues?
 Are you satisfied with your job?
 If unemployed, duration & reason? Is it due to current disease?

AP
ii. Finance:

H
 How much you earn per month? Or per day if daily worker?
 How many dependents?
C
 Is it enough to make both ends meet? ‫زگآرہوہاجتاےہ؟‬
EM

 Any other family member contributes?

iii. House & Surroundings:
AE

 Own or rental? Area? sunlight exposure?

.N

 How many persons live in it?

 How is water supply? it boiled? Use of bottled water?
R

 How is sewerage drainage?

D

 Any mosquitos around?

iv. Any pets, animals, cooking & milk:
 Exposure to pets, animals, birds?
 Is milk boiled before use?

v. Relationships & Domestic:
 Relationship with spouse
 Partner’s health, occupation, caring?
 Who else is at home? who cares most about you?
 10. Personal Antecedents to Disease:
What Investigations and treatment given during Hospital
stay in Emergency & indoor?
Patient education about Diagnosis, nature of disease, Rx
options?
11. Functional Status:
Ability to move, clothe, feed himself and maintain personal hygiene
12. Concerns:
‫آ پ ےک پڑڈتک امیبری ےک وحآےل ےس سب ےس پڑآ ہلئسم ایک ےہ ؟‬

Reflect back summary‫آ پےن ےھجمہی ھچکآیھبتکاتبتا ےہ؟‬.13

‫ایک آ پ وکیئ آیسی زیچ اتبتا اچںیہ ےگ وج ھجم ےس وپےنھچ ںیم رہ یئگ وہ ؟‬. 14

AP
‫ ایک آ پ اک وکیئ وسآل ےہ وج آ پ وپانھچ اچےتہ وہں ؟‬.15

H
C
EM

Examination
AE

Investigations
.N

I would like to request a SET of investigations regarding

R
D

1. Diagnosis
2. Complications
3. And to have baseline assessment prior to
starting some specific medications
 FEVER – History Taking
S
Duration
Onset Sudden, gradual
Intensity >101 °F = High grade, documented? at which site. Axilla?
Character/ Pattern
Intermittent high spike and rapid defervescence … tuberculosis, lymphoma, most pyogenic infections
Remittent fluctuating peaks and a baseline that does not return to normal;
fluctuations > 1°F
they can appear to be intermittent if antipyretic agents are administered.
e.g. endocarditis, sarcoid, lymphoma, and atrial myxoma…. Never say it 
Continuous fevers persist with little or no fluctuation
fluctuations <1 °F
but can appear to be intermittent if antipyretic agents are administered e.g. typhoid, drug fever
Relapsing fevers with periods during which patients are afebrile for one or more days between febrile
episodes may be seen with malaria, lymphoma

AP
Pel-Ebstein Relapsing fever with bouts of fever lasting 3-10 days ...e.g. lymphoma

H
C
EM
AE

Any predictable time

How it affects patient life? inability to sleep, excessive vomiting, bed ridden, unable to take orally)
Associated symptoms
.N

Connective Tissue, Rheumatic & Vasculitic Profile

R

Patchy hair loss, altered sensorium, seizures, redness or grittiness of eyes, oro-
D

genital ulcers, photosensitivity, rash , neck welling, heat or cold intolerance (thyroid),
palpitations (Libbman sack’s endocarditis), chest pain , shortness of breath,
abdominal distension (serositis), periorbital puffiness, hematuria, frothy urine,
diffuse tightening of skin, joint pains with morning stiffness, any changes in colour of
fingers on exposures to cold