Scribd Logo
Upload

Welcome to Scribd!

  • 16 views

    History Format MS

    Uploaded by

    mike sharew
    This document outlines the sections and topics to be covered in a patient history, including: 1. Patient identifying information, current hospitalization details, chief complaint, history of present illness, past medical history, review of systems, personal history, and family history. 2. The history of present illness section should cover date of onset, characteristics, exacerbating/relieving factors, and response to treatment. 3. The review of systems examines all body systems for current and past issues related to the chief complaint.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    History Format MS

    Uploaded by

    mike sharew
    16 views2 pages
    This document outlines the sections and topics to be covered in a patient history, including: 1. Patient identifying information, current hospitalization details, chief complaint, history of present illness, past medical history, review of systems, personal history, and family history. 2. The history of present illness section should cover date of onset, characteristics, exacerbating/relieving factors, and response to treatment. 3. The review of systems examines all body systems for current and past issues related to the chief complaint.

    Original Description:

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    This document outlines the sections and topics to be covered in a patient history, including: 1. Patient identifying information, current hospitalization details, chief complaint, history of present illness, past medical history, review of systems, personal history, and family history. 2. The history of present illness section should cover date of onset, characteristics, exacerbating/relieving factors, and response to treatment. 3. The review of systems examines all body systems for current and past issues related to the chief complaint.

    Copyright:

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

    History Format MS

    Uploaded by

    mike sharew
    This document outlines the sections and topics to be covered in a patient history, including: 1. Patient identifying information, current hospitalization details, chief complaint, history of present illness, past medical history, review of systems, personal history, and family history. 2. The history of present illness section should cover date of onset, characteristics, exacerbating/relieving factors, and response to treatment. 3. The review of systems examines all body systems for current and past issues related to the chief complaint.

    Copyright:

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

    = Full name, Age, Sex, Occupation, Address, Religion, name of

    admitted hospital, Hospital bed number, date of admission

    = previous hospitalization

    = Chief complaint

    =HPI
    + Date of onset

    + Mode of onset, course and duration

    +Character and location

    +Exacerbations and remissions

    + Effect of treatment

    + Negative-positive statements

    + Changes in strength, weight and color

    =Past illnesses
    + illnesses experienced in the past unrelated to the current
    illness

    + malaria, TB, HTN, DM, Cardiac, Renal, trauma, Asthma, allergy

    +surgery, anemia

    =ROS
    +Head: Headache, head injury

    +Eyes: Blurring of vision, pain, itching, lacrimation, photophobia

    +Ears: pain, deafness, ear discharge, vertigo, tinnitus

    + Nose: Nose bleeds, discharge

    +Mouth and throat: Gum bleeding, dental hygiene, sore throat

    +Respiratory system: Cough, expectoration (sputum),


    hemoptysis, chest pain, shortness of breath, wheezing, stridor

    + Cardiovascular system: Dyspnea (exercise intolerance),


    palpitation, orthopnea (number of pillows required),
    paroxysmal nocturnal dyspnea, swelling of legs, chest pain
    (anginal pain), syncope, intermittent claudication, fatigue
    + Gastroin
    Gastro-intestinal system: Loss of appetite, nausea, vomiting,
    dysphagia, (diarrhea, constipation), jaundice, colored stool

    + Genitourinary system: flank and suprapubic pain, hematuria,


    oliguria, polyuria, frequency, dysuria, urgency, dribbling,
    incontinence,

    + menstrual history (age at menarche/interval between


    periods/duration of flow/amount of flow), dysmenorrhea,
    menorrhagia, dyspareunia, amenorrhea, urethral or vaginal
    discharge, post coital bleeding, menopause, post-menopausal
    bleeding

    + Locomotor system: Joint deformities, bony deformities, joint


    pain or swelling, limping, loss of function of limbs or joints,
    muscle weakness or wasting

    + Central nervous system: Amnesia, speech disturbance,


    seizures, diplopia, vertigo, weakness of extremities, urinary
    incontinence or retention, fecal incontinence disturbance in
    sensation, insomnia

    = Personal history
    + Place of birth, childhood development, health and activities

    + Education, work, job hazards

    + Habits: Alcohol, tobacco smoking, illicit drug use, herbs

    + Marital status: Health of wife/husband, adjustment (marital


    harmony), number of children and their health

    =Family history
    Father and mother: Age, health, (if dead, mention date, age
    and cause of death)

    Siblings: List with ages, health (if dead, mention date, age, cause
    of death)

    Family disease: Diabetes mellitus, hypertension, migraine,


    asthma and other allergic diseases, other hereditary disease

    You might also like