Koya university - school of medicine

Case Record (history taking)

Personal Data:
Patient's name ........................................................................... Age ................ Sex .................

Residence .............................. Occupation ....................................... Religion ...............................

Marital status .......................................... Date of admission .............................................

Chief Complaint & Duration:

History of Present Illness:

• Site: general or local (where?)

• Onset: acute or insidious (sudden or gradual) - continuous or intermittent

• Character: burning - Stabbing - Sharp - Heaviness - Crushing - dull

• Radiation:

• Association: associated symptoms ex) vomiting/nausea/sweating/headache

• Time & duration: day - night - morning - midnight .....

• Exacerbated and relieved by:

• Severity: mild - moderate - severe rate (1-10): .........

Review of Systems:

General
Appetite: Fever: Sleep: Weight change: Energy:.
Fever (onset .........., Continuous ............, Day or night, associated with chills and rigor?
Gastrointestinal system, Abdomen & Pelvis

Upper GI tract:

• Pain (abdominal)

• Nausea

• Vomiting (projectile "forcefully propelled" or not , frequency .......... , Associated with diarrhea?

• Vomitus (color ............., bloody ........, Coffee grounds ........, amount .............), Contain pus ?

• Hematemesis (vomiting blood)

• Water brush (watery mouth)

• Xerostomia (dry mouth)

• Heartburn

• Dysphagia (difficulty swallowing)

• Odynophagia (swallowing is painfull)

• Flatulence (bloating, gas)

Lower GI tract:

• Diarrhea (frequent bowel motion): (onset, frequency, color, amount, consistency,

pain during diarrhea, contain blood, froth, mucus? , Associated with vomiting?

• Constipation

• Stool color: pale, dark, tarry black (melena), fresh blood (hematochezia).

Liver & Gallbladder:

• Jaundice (yellow discoloration of skin and sclera)

• Urine color .................... Itching ...................... History of injection .................................

Recent travel abroad ..................................... Alcohol intake ......................
Other cases of jaundice (family ................. Friend............. Work...............)
Cardiovascular system

• Chest pain or Tightness (on exertion): site ................... Severity..................

• Dyspnea (SOB) : severity ..................., On rest or exertion (degree of exertion) ........................

Lying flat (orthopnea) .......... At night "sleep" (paroxysmal nocturnal dyspnea) ....................

• Palpitation (regular or irregular, at day, at night, with dyspnea or not?, continuous or not?)

• Cough (froth, hemoptysis)

• Edema

• Intermittent claudication

• Past history of Rheumatic fever or chorea

• Cyanosis

Respiratory system

• Cough (dry, productive "wet" , painful, duration)

• Sputum (amount .............. Time of day ................ color & odor ............... purulent or not (pus)

• Hemoptysis (blood in sputum): severity ............. Amount .............

• Wheeze: (when it occur ..............., Continuous or intermittent, provocative factors ..................)

• Chest pain: (site ...................................... Relation to respiratory cycle ........................................)

• Dyspnea

• Cyanosis
Urinary system

• Loin pain (character .................. Radiation ............... Unilateral or bilateral)

• suprapubic pain (character .................. Radiation ...............), Loin pain (uni or bilateral)

• Pain on passing urine (dysuria)

• Urine: amount .................. Frequency ...................... Nocturia (amount, times) .......................

Stream ..................... Incontinent ............... Color ............... Froth ...............

• Haematuria: (at what period of micturition .......................)

• Morning puffiness of face, ankle swelling, dyspnea

• Headache, vomiting, drowsiness, fits

Genital system
Male (urethral discharge, scrotal swelling, ulceration of penis or scrotum)

Female (discharge, swelling, itching)

Functional disorders (impotence, premature ejaculation, frigidity)

Blood

Lassitude, dyspnea, palpitation

Recurrent infection

Blood loss (gum, epistaxis etc. )

Petechiae & purpura

Glandular enlargement

Past history of bleeding tendency

Drug history (NSAIDs, antibiotics etc.)

Family history of blood disorders

Skin

• Itching: (at what period of day .................................... Provocative factors ...................................

Local or general

• Skin eruption

• Hair fall

• Animal, plant or insect contact

• Cosmetics

• Drug intake & chemical exposure

• Personal or family history of asthma or hay fever

Nervous system
Patient may present with :-

1) Stroke , TIA, RIND

sensory or motor

Associated headache at onset (suggest hemorrhage or migraine)

History of heart or vascular disease

2) Epilepsy (age of onset of 1st attack .................... Intervals between attacks .............................

Occurrence during sleep ..................)

• presence and character of aura

• Loss of consciousness

• Seizure: focal, absence, general

• Convulsion

• Postictal symptoms: (headache, sleeping, paralysis, fatigue)

• witness of the attack

• History of head injury, ear infection, brain operation

• family history
3) Other neurological symptoms

• Dizziness & vertigo

• Visual disturbance

• Speech disturbance

• Proximal muscle weakness (myopathy)

• Distal weakness & sensory loss (peripheral neuropathy)

• Tremor

• numbness

Locomotor system

• Bone pain (deep & boring) (worse in the day or at night)

• Muscle pain

• Joint pain ± swelling (constant or on movement, which joint? .......................) Redness & warmth

• Limitation of movement

• Migratory pain

• Associated skin conditions (dermatomyositis, psoriasis, SLE, and scleroderma)

• Associated GI disorders (ulcerative colitis, inflammatory bowel disease IBD)

• Associated eye condition (conjunctivitis, uveitis)

• Urethral or vaginal discharge (reiter's syndrome)

• Previous history of rheumatoid arthritis, Rheumatic fever, or gout

• Morning stiffness

Endocrine system
• Heat or cold intolerance (like winter or summer?)

• Change in sweating

• Excessive thirst (polydipsia)

Past history

Medical: HT, DM, IHD, CVA, asthma, anemia, infectious (TB, HIV, sexually transmitted diseases)

Surgical: operations, injuries, trauma (times .............., Site .............................., Date .........................)
Occurrence of complications

Anesthesia: (complications)

History of blood transfusion

Treatment History Including medical surgical & radiotherapy

• Drugs (current & used ) ..............................................................................................................

• drug hypersensitivity "Allergy"

• Self- medication & drug abuse

• Blood transfusion

Menstrual history

• Age of menarche

• Menstrual cycle (frequency, regularity, duration "usually 28 days" , amount of blood)

• menorrhagia or oligomenorrhea (2-8) days

• Presence or absence of menstrual pain

• Use of oral contraceptive

• Age of menopause

• Postmenopausal symptoms (hot flashes "sweating" , anxiety, palpitation

Obstetric History

• Childbirth (number........., Course of pregnancy ........................................)

• Stillbirths

• Miscarriages

• Antepartum & postpartum hemorrhage

• Purperium (complications, failure of lactation)

Family history

• Patient's position

• Ages of children if any

• Immediate relatives (state of health, important illness, cause of death)

• Important illnesses (HT, DM, IHD, CVA, infectious disease e.g TB)

Social history

• Social class (low, high) & physical environment

• Habits, hobbies, sports

• Home surroundings (overcrowding, water supply, sewage drainage, pets)

• Domestic animals & pets (where they are kept, from where brought)

• Domestic & marital relationships

• Smoking (current & past, duration & number)

• Alcohol (current & past, duration & amount) type

• Travel history (remote & recent)

Occupational history
• any exposure to dust, fumes, vapours, chemicals, sensitizing agents, animal, contaminated
needle or syringe

• possible affect of any drug on patient's occupation (e.g. antihistamine)

• Similar illness occur in other fellows at work