ge: state of health)
Guide For Medical History
Topic
CC:Chief
Complai
nt
HPI
History
of
Present
Illness
Description
This is patient’s major presenting complaint and its duration. Use patient’s own words if possible, i.e. chest
pain x 2 hr. Limit CC to one (1) complaint. if there is no complaint and patient is presenting for routine hx and
P/E. then so state, i.e—CC: none. Diagnostic procedures, operations are not to be used as CC. instead, use
that complaint that necessitates the procedure or operation
This is the filling in of background information relevant to the chief complaint. It must be a chronological
narrative of the CC that is brief, lucid, and easily digested
1. Your opening sentence will be clumsy: include patient’s age, race, occupation, sex and general
state of health prior to onset of presenting illness, in addition, include pertinent chronic diseases;
the details of which will go in past medical history. I.e.—This is the second hospitalization with a 3
yr. History of Diabetes Mellitus and 10 yr. history of High Blood Pressure who was in his usual state
of health until this 9 a.m. today when he developed
Give complete analysis of symptoms:
(See Chart: ANALYSIS OFA SYMPTOM)_”LORCATES”
a. Onset
i. Date of onset (also determines total duration)
ii. Manner of onset (gradual or sudden)
iii. Precipitating and predisposing factors related to onset (emotional disturbance,
physical exertion, fatigue, bodily function, pregnancy, environment, injury,
infection, toxins and allergies, therapeutic agents).
b. Characteristics at onset (or any other time)
i. Character (quality) sharp, dull.
ii. Location and radiation (for pain).
iii. Intensity or severity - rate on scale of 1-10 if pain.
iv. Temporal character (continuous, intermittent, rhythmic; duration of each;
relationship to other events).
v. Aggravating and relieving factors.
c. Associated symptoms Course since onset
i. Incidence
1. Single acute attack
2. Recurrent acute attacks
3. Daily occurrences
4. Periodic occurrences
5. Continuous chronic episode
ii. Progress (better, worse, unchanged)
iii. Effect of therapy
3. When symptoms point to a particular system(s), all questions included under that review of
system(s) should be asked with positives and negatives recorded in the HPI.
4. Mention pertinent medical problems and give details in PMHX.
5. Include pertinent family history; i.e., Renal, Heart Disease, HBP, Anemias, etc.
6. include pertinent social factors, i.e., tobacco, ETOH abuse, occupational hazardous exposures,
stresses, etc.
7. Allergies: Include positives and/or negatives.
8. Medications: List all current prescription and OTC drugs. Note dosages, frequency and duration.
(include laxatives,ASA, vitamins, etc.)
a.
1. Medical
a. Child:Measles, rubella, chicken pox, mumps, whooping cough, scarlet fever, rheumatic
fever, diphtheria, poliomyelitis, general picture of health as child.
b. Adult:List all past illnesses, the time of occurrence, the nature of the symptoms in the
illness, the type of therapy, the complications, and the diagnostic label, if known - do not
list diagnosis only as these can be misleading. Specifically inquire about common
diseases: stroke, heart disease, kidney disease, hypertension, tuberculosis, diabetes,
venereal disease, anemia.
2. Surgery: Date of each operation, nature of symptoms prior to operation, type of operation,
complications, results of operation.
3. Hospitalization: Patients will often forget disease processes; therefore, ask specifically about
hospitalization and record major symptoms leading to hospitalization, studies carried out, diagnosis,
treatment, and results of treatment (outcome).
4. Injuries:
a. Date, cause, type, complication, outcome.
Immunization and Vaccination:
Record the time and results of any and all vaccinations and immunization - include specifically tetanus,
smallpox, measles, german measles, mumps, hepatitis, pneumococcal, influenza, typhoid, para-typhoid,
tuberculin testing, poliomyelitis.
The Family History should contain the medical history of the patients spouse, siblings, parents and
2.
PMH:Past
History
Family
History
grandparents (2 generation regression) Details should include the following information if applicable:
1. Diseases
2. Cause of death
3. Age of death
The above data can be recorded in the following tabular form:
4.
History of familial disease; cancer, leukemia, lymphoma, migraine, tuberculosis, coronary artery
disease, hypertension, nephritis, strokes, nervous or mental disturbances, anemia or other
hematological disorders, diabetes, obesity, thyroid disturbances, allergy, and other disease
suggested by the patient’s history. Include positives and negatives.
5.
Genetic history- sufficient information should be included to ascertain the patients risk of genetic
diseases, The table demonstrated above represents an effective mechanism to track both known
genetically inheritable diseases as well as familial patterns of diseases without known genetic
patterns
Social
History
Place of birth, ethnic lineage, residence and travel (foreign and
domestic) include military.
1.
Habits
a.
Sleep
b.
Tobacco-(quantitate in pack years or other)
c.
Diet
d.
Laxatives, sedatives, other drugs
e.
Fluid Intake
f.
Vitamins
g.
Coffee/tea
h.
Avocation and recreation
i.
Alcohol Intake (quantitate)
j.
Exercise
2.
Education: Schooling
3.
Occupational History:
4.
Past and present work and exposure to known physical/environmental hazards.
5.
Frequency of jobs and duration of each job.
6.
Work environment and the number of hours at work.
7.
Attitude (satisfaction, security) toward work and employer.
8.
Marital status - # marriages, quality of relationships, children.
9.
Environment (community, living conditions, number in household, flights of stairs, amount of
housework).
10. Support system (friends, community involvement, quality of relationships).
ROS:Revie
w of
Systems
This is basically a comprehensive screening process designed to:
1.
uncover additional problems related to the CC
2.
uncover concurrent problems. Be sure to indicate to the patient that this review is a routine
procedure. Question the patient for symptomatology generally within the last six (6) months.
Positive responses must be elaborated upon. If symptoms have persisted for longer than 6 (six)
months, put in past medical history. When particular system has been included in your HPI then so
state: i.e. — G.I. see HPI. Arrange ROS in the following order:
General:
Present weight (amount of loss or gain over what period of time and contributing factors; i.e., dieting,
anorexia, etc.), weakness, fatigue, malaise, fever, chills, sweats or night sweats.
Skin:
Lesions, color changes, pruritus, tendency to bruising, excessive dryness, texture, hair and nail
changes, use of hair dyes or other possibly toxic agents.
Head:
Cephalgia, trauma, syncope, lightheadedness.
Eyes:
Vision (general), glasses (reason for glasses), pain, diplopia, scotomata, photophobia, lacrimation,
inflammation, injection, discharge, field cut, injury, previous surgery, medications, date of last eye
exam.
Ears:
Injury, past disease, decreased hearing, discharge, pain, vertigo, tinnitus.
Nose:
Obstruction, headcolds, discharge, epistaxis, loss of smell, abnormal odors, frequent sneezing.
Mouth:
Excessive salivation or dryness, pain ulceration, bleeding.
Tongue:
Enlargement, soreness, coating, loss of sense of taste, injury.
Teeth:
General condition, pain, abscess, impaction, dental extraction.
Gums:
Bleeding, swelling, ulceration, and discoloration.
Throat:
Sore throat, tonsillitis, abscess, difficulty in swallowing, nasal discharge.
Neck:
Stiffness pain, welling, pulsations, limitation of motion larynx, hoarseness, change in voice, aphonia,
respiratory stridor.
Nodes:
Tenderness or enlargement of neck, axillary, epitrochlear or inguinal nodes.
Breasts:
Masses, tenderness, deformity, abnormal discharge.
Cardiovascular:
Dyspnea, orthopnea, paroxysmal nocturnal dyspnea, edema, palpitation, irregular heart action,
chest pain (characteristics, radiation, duration, relation to exercise, relation to posture, eating,
effects of drugs) -edema, coldness of extremities, claudication, night cramps, ulceration of
extremities, gangrene, color changes in extremities, etc., date of last IEKG (if appropriate) and
results
Respiratory:
Cough, sputum (character, amount, color, odor), hemoptysis, night sweats, chills, fever, wheezing,
shortness of breath, pleural pain, injury, date of last chest x-ray; if abnormal, what was problem.
Gastro-Intestinal:
Appetite, food allergy, nature of diet, selective dyspepsia, dysphagia, beichi heartburn, sour stomach,
nausea, vomiting, hematemesis, jaundice, epigastric distress (relation to meals, relief by antiacids,
eating or belching), abnormal pain (location, radiation, causation, and characteristics - sharp, knifelike, colicky, dull, aching, gnawing, constant, intermittent, severity (patient’s relation to pain), mode of
obtaining relief, and so forth: gas - excessive belching, flatus, borborygmus; bowel movements regularity, frequency, change in habit, laxatives; stools color, consistency, size, shape, odor, bloody
or tarry; painful defecation, tenesmus, hemorrhoids. Has Barium enema ever been performed? If yes,
why and what were results?
Genito-Urinary:
Voiding per day, dysuria, urgency, frequency, hematuria, pyuria, incontinence, difficulty in starting or
stopping stream, size of stream, appearance of urine, stones or gravel, past venereal disease,
previous surgery, lumbar or flank pain, uretheral discharge, penile and perineal sores, sexual
contacts, change in sexual drive or activity, testicular pain, scrotal changes. Have kidney x-rays or
bladder diagnostic procedures ever been necessary? If yes, what and what were results?
Gynecological:
Age of onset of menstruation, frequency of menstruation, duration, amount of flow, presence of clots,
dysmenorrhea, date and character of last period, leukorrhea, recent change of cycle, date and age of
menopause, menopausal symptoms, coital bleeding, post-menopausal bleeding, pregnancy, (with or
without complications of each pregnancy), previous surgery, time of last pelvic examination, venereal
disease, changes in sexual drive or activity, birth control.
Extremities:
Vascular: Intermittent claudication, varicose veins, ulceration, color changes. coldness of extremities,
hair loss, gangrene, thrombophlebitis.
Pain (note location, migratory nature, relation to known cardiac involvement), swelling, limitation of
motion, pain on motion, morning stiffness.
Bones: Flat feet, fracture.
Muscles: Pain, cramps.
Joints-stiffness, immobility
Back:
Pain (location and radiation, especially to the extremities), stiffness limitation of motion, injury.
Central Nervous System:
General: syncope, loss of consciousness, convulsions, dizziness.
Mentative: speech disorders, emotional status, orientation, memory disorders, change in sleep
pattern, history of nervous breakdown.
Motor: tremor, weakness, paralysis, clumsiness of movement.
Sensory:anesthesia, parasthesia, pain.
Hematopoietic:
Bleeding tendencies of skin or mucus membrane, anemia and treatment, blood type, transfusion(s)
and reaction, exposure to toxic agents or radiation.
Endocrine:
Inquire specifically about symptoms of diabetes (polydipsia, polyphagia, and polyuria),
hyperthyroidism, hypothyroidism, weight loss or gain (specify pounds per unit time), estimation of
food intake, unusual sensitivity to cold or heat, excessive perspiration, excessive nervousness, fine
tremor, development of striae, alterations in bodily contour.
Emotional State:
Nervousness, excessive crying, depression, euphoria, hallucination, sleep pattern, concentrating ability,
previous treatment, drugs, or hospitalizations.