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    Mohammed Gogandy - Medicine History Sheet & - 40 2007-2008& - 41 PDF

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    Jennifer Ross-Comptis
    This document outlines the sections and information to include in a patient's medical history and examination report. It includes sections for personal data, presenting complaint, history of present illness, hospital course, review of major body systems, allergies, current/past medical history, social history, family history, and summary. The history of present illness section provides guidance on analyzing symptoms chronologically. It also describes documenting any relevant chronic conditions, including details on diagnosis, treatment course, and disease management. The review of body systems lists common symptoms to inquire about for each system.

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    Download as PDF, TXT or read online from Scribd

    Mohammed Gogandy - Medicine History Sheet & - 40 2007-2008& - 41 PDF

    Uploaded by

    Jennifer Ross-Comptis
    297 views2 pages
    This document outlines the sections and information to include in a patient's medical history and examination report. It includes sections for personal data, presenting complaint, history of present illness, hospital course, review of major body systems, allergies, current/past medical history, social history, family history, and summary. The history of present illness section provides guidance on analyzing symptoms chronologically. It also describes documenting any relevant chronic conditions, including details on diagnosis, treatment course, and disease management. The review of body systems lists common symptoms to inquire about for each system.

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    Mohammed Gogandy - Medicine History Sheet &_40;2007-2008&_41;.pdf

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    This document outlines the sections and information to include in a patient's medical history and examination report. It includes sections for personal data, presenting complaint, history of present illness, hospital course, review of major body systems, allergies, current/past medical history, social history, family history, and summary. The history of present illness section provides guidance on analyzing symptoms chronologically. It also describes documenting any relevant chronic conditions, including details on diagnosis, treatment course, and disease management. The review of body systems lists common symptoms to inquire about for each system.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    297 views2 pages

    Mohammed Gogandy - Medicine History Sheet & - 40 2007-2008& - 41 PDF

    Uploaded by

    Jennifer Ross-Comptis
    This document outlines the sections and information to include in a patient's medical history and examination report. It includes sections for personal data, presenting complaint, history of present illness, hospital course, review of major body systems, allergies, current/past medical history, social history, family history, and summary. The history of present illness section provides guidance on analyzing symptoms chronologically. It also describes documenting any relevant chronic conditions, including details on diagnosis, treatment course, and disease management. The review of body systems lists common symptoms to inquire about for each system.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    MEDICINE HISTORY

    1-PERSONAL DATA: -Name -Age -Sex -Nationality -Date of admission (OPD – ER)
    -Any known illness (Duration + Medication)
    2-MAIN COMPLAINT + DURATION
    3-HISTORY OF PRESENTING ILLNESS (HPI): (check the note)
    -Complaint analysis (e.g. Pain analysis {SSDN OOPPERRA}: Site – Severity – Duration - Nature
    On & Off/Continues - Onset - Progression – End – Radiation – Precipitating, Relieving
    & Aggravating Fs)
    -Associated symptoms
    -Previous episodes
    -Review of related system
    -Risk factors
    -Special questions related to the differential diagnosis / Important negatives
    -History of any chronic disease (check the note)
    4-HOSPITAL COURSE:
    -What happened since admission: Improving / Worsening
    -Investigations done + Findings
    -Medications given
    -New diagnosis
    -New complaints
    -Plan (or reason for hospital stay)
    5-SYSTEMIC REVIEW:
    -CVS: Chest pain – Dyspnoea – Orthopnea – PND - Easy fatigability - Cold extremities
    Syncope - Intermittent claudication - Palpitation – Ankle swelling – cyanosis
    -Respiratory: Cough – Sputum – Heamoptysis – Sore throat – Hoarseness - Wheeze – Fever
    Night sweat – Chest pain – Dysponea
    -GIT: Appetite – Weight change – Nausea – Vomiting - Heamatemesis - Heart burn
    Regurgitation - Dysphagia – Odynophagia – Fever - Abdominal pain - Distention
    Change in bowel habits – Hematochezia - Melena – Incontinence – Jaundice
    Pruritis - Dark urine – Pale stool
    -Urinary: Loin pain – Dysuria – Anuria – Polyuria – Nocturia - Heamaturia - Incontinence
    Urethral discharge – Urgency – Weak stream - Dribbling - Frequency
    Hesitancy - Change in urine color – Retention - Incomplete emptying
    -Menses: Regularity – Menorrhagia – Oligomenorrhea – Amenorrhea - Dysmenorrhea
    Vaginal discharge – Genital Rash – Infertility - Breast pain – Nipple discharge
    Menarche - Menopause - Pregnancies (Number + Complications)
    -Endocrine: Appetite – Weight change – Sweating – Skin changes - Galactorrhea
    Abnormal Pigmentation – Polyuria – Polydepsia – Polyphagia - Lethargy
    Impotence – Heat or Cold intolerance – Neck swelling - Menstruation
    -CNS: Headache – Back or Neck pain – Facial pain – Dizziness – Vertigo – Gait disturbance
    Tremor – Numbness – Sensation loss - Limb weakness – Involuntary movements
    Swallowing disturbance - Fits or convulsions – Loss of consciousness
    Sphincter control - Vision/Hearing/Smell/Speech abnormalities
    -Rheumatology: Joint (Pain – Swelling – Deformity – Loss of function – Weakness
    Limitation of movements – Morning stiffness – Instability) - Bone pain - Myalgia
    Back pain – Dry mouth or eye – Red eye - Mucosal ulcers - Raynaud’s phenomenon
    Rash – Fatigue – Fever
    -Dermatology: Rash – Pruritis – Skin changes – Pigmentation - Changes in hair distribution

    medbooksvn.org
    -Hematology: Symptoms of anemia (Dyspnoea – Fatigue – Headache – Faintness - Palpitation
    Postural dizziness) – Jaundice – Bone pain - Prolonged bleeding – Easy bruising
    Skin rash - Paraesthesia - Neck / Axillary / Inguinal swellings (Lymph nodes)
    6-ALLERGIES
    7-CURRENT MEDICATIONS: -Name -Duration -Dose -Side effects
    8-PAST HISTORY:
    -Medical: HTN – DM – Asthma – IHD – RA – TB – CVA – MI - Hyperlipidemia – Other
    -Surgical: -Previous surgeries
    -Previous procedures (e.g. Endoscopy)
    -Blood transfusion: When – Times - Units – Complications – Packed RBCs/Platelets/FFP . . .
    9-SOCIAL HISTORY: Marital status – Job & Income – Education – Home – Travel – Alcohol
    Drug abuse - Smoking (Duration + Number of packs per day) - Animals contact
    10-FAMILY HISTORY: Similar illness – History of cancers – HTN – DM – Asthma – IHD
    CVA – MI – Hyperlipidemia – Blood diseases – Other
    11-SUMMARY: -Name -Age -Sex
    -Main complaint + Duration -Known illnesses
    -Associated symptoms -Important findings (depend on the case)
    Note:
    (How to write a proper HPI)
    -Put your story into a chronological sequence.
    -Start from the last day in which the patient was in his/her usual state of health.
    -You have to include in your story:
    -Analysis of each symptom (Each symptom has its special analysis)
    -Other hospital visits
    -Investigations done + Findings
    -Surgeries or procedures done
    -Medications used
    -Improvement or worsening of symptoms after medications use
    -Reason of presentation this time
    -Analyze any positive symptom you find in your systemic review.
    (History of any chronic disease)
    -Since when?
    -Diagnosed in which hospital?
    -What were the presenting symptoms?
    -What investigations were done to confirm the diagnosis?
    -Medications being used / Surgeries were done.
    -Improving / Worsening with the medications.
    -Medications compliance? Home monitoring of the disease? By what? What are the usual readings?
    -Following up in which hospital? Who is the treating doctor?
    -Chronic or persisting symptoms.
    -Exacerbations of the disease (Acute attacks – Acute complications)? Precipitating factors?
    -Hospital admissions / ICU admissions.
    -Complications? Follow up in other clinics to treat the complications.
    DONE BY:
    Mohammed Gogandy
    House Officer – 2007 / 2008
    がんばって ください 。。。
    Version - 2

    medbooksvn.org

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