Medicine History
1- PERSONAL DATA
Name: Nationality:
Age: Date of admission.:(OPD-ER)
Sex: Any known illness( duration+
medication)
2- Main complaint……………………. Duration……………….
3- History of presenting illness (HPI)…….. …………..……… ……………
………… ……… …………………………….
Complaint analysis ( pain analysis): SSDN OOPPERRA
a- Site…………………………… b- severity………………………. …….
c- duration……………………… d- nature (off-on/continues)
……………………
e- onset………………………….. f-progression…………………………..
g- end………………………………. h- radiation………………………………
i- precipitating ,relieving &aggravating Fs………………………….
…………………………………………………………………………………..................
j- associated symptoms…………………………………………………….
k- previous episodes…………………………………………………………..
l- review of related systems……………………………………………
m- Risk factors……………………………………………………………………
n- special Q related to the D.D/ imp. –ve………………………………….
……………………………………………………………………….
o- history of any chronic diseases………………………………………………
4- HOSPITAL HISTORY:
- What happened since admission: Improving………….. / worsening…………..
- investigations done + finding………………………………………
- medications given……………………………………………………………
- New Dx…………………………………………………………………………..
- New complaints……………………………………………………………...
- Plan or reason for hospital stay………………………………….
5-SYSTEMIC REVIEW :
Respiratory:
Cough Sputum
Heamoptysis Sore throat
Hoarseness Wheeze
Fever Night sweat
Chest pain Dyspnea

CVS:
Chest pain Easy fatigability Palpitation
Dyspnea Cold extremities Ankle swelling
Orthopnea Syncope cyanosis
PND Intermittent claudication
GIT:
Appetite Wt. change Nausea
Vomiting Heamatemesis Heart burn
Regurgitation Dysphagia Odynophagia
Fever Abdominal pain Distention
Pruritis Hematochezia Melena
Incontinence Jaundice Pale stool
Dark urine Change in bowel habit
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 ( NO. + complications)
Endocrine:
Appetite Wt.change Sweating
Skin changes Galactorrhea Abnormal
pigmentation
Polyuria Polydepsia Polyphagia
Lethargy Impotence menstruation
Neck swelling Heat or cold intolerance

CNS:
Headache Back or neck pain Facial pain
Dizziness Vertigo Gait disturbance
Tremor Numbness Sensation loss
Limb weakness Involuntary movement Swallowing
disturbance
Fits or convulsion Loss of consciousness Sphincter control
Vision/hearing/swelling/smell/speech abnormalities
Rheumatology:
Joint ( pain……….swelling………..deformity………..loss of function…………..
Weakness…………..limitation of movement…………morning stiffness..........
instability…………)
Bone pain Myalgia Back pain
Dry mouth or eye Red eye Mucosal ulcer
Fever Rash fatigue
Raynaud's phenomenon
Dermatology:
Rash Pruitis Skin changes
Pigmentation Changes in hair distribution
Hematology:
Symptoms of anemia (dyspnea………….fatigue………..headache……….faintness
………..palpitation…………postural dizziness………..)
Jaundice Bone pain Prolonged bleeding
Easy bruising Skin rash Paraesthesia
Neck/axillary /inguinal swelling ( lymph node)
6-ALLERGIES
7- CURRENT MEDICATIONS:
- name…………………………………… - duration…………………………………
- dose……………………………………. – side effects………………………….
8- PAST HISTORY:
- medical: HTN…… D.M……… asthma……. IHD……….. RA…………..
T.B………. CVA…….. M.I…………. hyperlipidemia…………
- surgical: previous surgeries………………… previous procedures………
- blood transfusion: when……………….. time……………. Units………
Complications…………………………………………..
9- SOCIAL HISTORY: marital status…………………… job& income……………

Education…………………home………….travel………………. alcohol……………………….
Drug abuse…………….. smoking (duration……………..NO. of packs per day…..
10 –FAMILY HISTORY: similar illness………………..history of cancers………..
HTN……..D.M…….asthma………IHD……….CVA……….
MI…… hyperlipidemia…………blood diseases……….
11- SUMMERY: - name - age - sex
- main complaint +duration - known illness
-Associated symptoms - imp. findings
#NOTE:
How to write a proper HPI??
• put your story into a chronological sequence.
• Start from the last day in which the pt. was in his/her usual
state of health
• You have to include in your story:
-analysis of each symptoms
- other hospital visits
- investigations done + finding
-Surgeries or procedures done
- medications used
- improvement or worsening of symptoms after medications use
- reason of presentation this time.
• Analyze any +ve symptoms 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 Dx?
• 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 attack-acute
complications) precipitating factors?
• Hospital admissions / ICU admissions
• Complications ? Follow up in other clinic to treat the
complications