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