Home 
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Lecture
for 4th year medical students on December 24, 2013 by Professor Omar Hasan
Kasule Sr.
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1.0
DEMOGRAPHIC
INFO
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Name
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Age
and date of birth
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Residential
address
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Occupation
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2.0
HISTORY OF
PRESENTING COMPLAINT(s)
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Complaint
#1: Onset, course, location (site), radiation, severity, time of day,
duration, diurnal variation, character, aggravating factors (food, cough etc
), relieving factors, associated symptoms
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Complaint
#2:
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Complaint
#3:
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Complaint
#4:
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What
does the patient think is going on?
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Treatments
already given
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Effect:
work, daily life, sports,
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3.0
PAST MEDICAL /
SURGICAL HISTORY
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Chronic
illnesses like HT, DM, Cardiac
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Hospitalizations
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Surgeries
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4.0 ALLERGY HISTORY
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Reactions
to medications: type and drug
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Food
allergies
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Environmental
allergies
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5.0 MEDICATION HISTORY
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List
of current medications doses and why: prescribed or OTC?
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List
of chronic medications
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Medicine
stopped
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Herbal or complimentary medications
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6.0 FAMILY
HISTORY
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Parents:
age, height, weight, health status, consanguinity, region of origin
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Siblings:
names, nicknames, age, height, weight, health status
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Significant
problems maternal & paternal
sides: arthritis, DM, HT, renal disease, anemia, headache, TB
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Diseases
that run in the family
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Specific
question about illnesses resembling presenting complaint: thyroid disease,
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7.0 SOCIAL HISTORY
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Type
of housing, location (city vs rural), how many people in house
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Education,
occupation, income, religion and culture, smoking
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Health
insurance
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Contact
with animals
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8.0 RISK FACTORS
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9.0 REVIEW OF SYSTEMS (If not covered in
presenting complaints and PMH)
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Skin:
skin rash, pigmentation, bruising
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CVS
and RES: chest pain, cough (hemoptysis), dypnea (orthopnea, nocturnal
dyspnea), cyanosis, palpitations, ankle swelling,
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Hematological:
pallor, jaundice, bone pain, bruises, epsitaxis
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GIT:
Vomiting, nausea, dyspepsia, dysphagia, abd pain, diarhoea / constipation,
Bowel habits, feeding, weight loss / gain, rectal bleeding
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Urinary
tract: dysuria, enuresis, frequency., nocturia, hematuria, incontinence,
urethral discharge
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Genital:
menstruation (regularity, length, volume), impotence,
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CNS:
irritability, drowsiness, collapse / blackout, abnormal movements (seizures), headache,
numbness, dizziness and loss of balance, vision, hearing, headache
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Musculoskeletal:
joint swelling, joint pain, skin rash, movement restrictions, muscle wasting,
spasms,
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