The document outlines guidelines for medical students on how to conduct patient interviews and document histories, emphasizing the importance of communication, clarity, and sensitivity. It details how to gather and present patient history, including chief complaints, present illness, and relevant medical and social histories, while avoiding medical jargon. Specific questioning techniques and common symptoms for various conditions are also provided to aid in effective patient assessment.

1. Medical college of wasit
Department of medicine
Case sheet history
Thing to remember :-
1) Stand on the right side of the patient with good confidence .
2) Introduce yourself as a medical student not as a doctor . ( you may face difficult
question ).
3) Talk the patient gently with clear comprehensible words .
4) Remember don’t hurt the patient in your speak & touch .
I.D :-
Name :-
Age :-
Sex :-
Occupation :-
Address :-
Religion :-
Marital status :-
Residency :-
Date of admission :-
Blood group & RH :-
Chief compliant & duration :-
These compartment posses the main cause that made the patient get hospital & here you
should avoid the medical terms . It should be a symptom not a sign .
* The symptom discovered by a patient & the sign observed by a doctor .
Example :-
 Diarrhea = frequent bowel motion
 Constipation = infrequent bowel motion
 Vomiting = explosion of gastric content or ( same term )
 Fever = increase body temp.
 Dysphagia = difficulty in swallowing
 Dysponea = shortness of breath
 Fit = abnormal involuntary movement
 Headache = same term
 Pain = same term
 Edema = swelling of part of the body
 Jaundice = yellow discoloration of the skin & sclera
 Hematemesis = blood on vomitus
BY : OSAMA HADI

2.  Hemoptysis = blood in sputum
 Cyanosis = bluish discoloration of the skin & sclera
 Weakness = same term
 Mass = same term
* common fault :- Hypertension is not a chief compliant but may belong to headache .
History of present illness :-
It is the main part of the history & should be careful to :
1) Write as paragraph.
2) Avoid medical term .
3) Avoid leading question .
4) In this part you should discuss the system that the chief complaint belongs to .
5) Write the status of the patient after admission & receiving therapy ,is he /she feeling
well or not ?
How to start present illness ?
By two ways :-
1) If the patient has a chronic condition previously such as ( diabetes , hypertension …)
write as : the patient is a known case of …… for duration presented with …..
2) The condition started when the patient ( suddenly or gradually ) complained
of ……
what are the questions to ask ?
 Pain - Site .
 Continuous or intermittent ?
 Localized or diffused ?
 Radiation .
 Intensity ( severe , moderate ) .
 Character ( stabbing , colicky , …) .
 Aggravating factors .
 Relief factors .
 Associated symptoms .
 Time & duration .
 Fever ( 36.6 - 37.4 c )
_ Sudden or gradual ?
 Grade of fever .
 Pattern of fever .
 Aggravating factors .
 Relief factors .
 Associated with chills ?

3. * There are many patterns of fever :-
1) Continuous fever : daily fluctuation do not exceed 1 c ( typhoid fever ).
2) Remittent fever : daily fluctuations exceed 2 c ,but never touch normal ( brucellosis
, T.B ) .
3) Intermittent fever : temp. touch normal for several hours in a day ( JRA , malaria ).
4) Quotidian : when the paroxysm of the intermittent fever occurs daily ( every day ).
5) Tertian : when the paroxysm of the fever occurs on the alternate day ( every 48
hours ).
6) Quartan : there is interval of 2 days between consecutive attacks .
7) Pel Ebstein fever : in Hodgkin's disease , the temp. range between ( 38.8 - 39.5 c).
* Common causes of fever :-
It could be classified under that due to :
o Infectious disease .
o Connective tissue disease .
o Malignant disease .
o Miscellaneous .
 Diarrhea - Frequency .
 Continuous or intermittent ? if intermittent duration of period
during which patient free from symptom & had symptom .
 Color , quantity , order , content .
 Is the diarrhea accompanied with mucous or blood ?
 Associated with other symptom ( loss of weight , fever , vomiting
, abdominal pain ) .
 History of food intake before the episode ( food poisoning ) .
 History of tinnismus .
 History of diarrhea in the same vicinity .
* Common cause of diarrhea :-
1) Chronic :-
 Irritable bowel syndrome .
 Inflammatory bowel disease .
 Malabsorption .
 Laxative abuse .
 Drug therapy .
 Hyperthyroidism .
 Post - bowel resection .
 Colorectal cancer .

4. 2) Acute :-
 Infective gastroenteritis .
 Drug ex. antibiotic .
 Vomiting - Frequency .
 Forceful or projectile ( meningitis ) ?
 Relationship between food & vomiting .
 Any special time of vomiting .
 What is the amount , smell , color & content of vomitus ?
 Any blood in vomitus ? amount & color .
 Associated symptoms .
* Common cause of vomiting :-
1) Neurological :-
 Raise intracranial pressure e.g. brain tumor .
 Middle ear disorder e.g. lybrinthitis .
 Migraine .
2) Severe pain :-
 Myocardial infarction , renal colic .
3) Drug :-
 Alcohol , digoxin , cytotoxic agent .
4) Metabolic / endocrine :-
 Pregnancy .
 Diabetic ketoacidosis .
 Addison's disease .
5) Psychological :-
 Anorexia nervosa .
6) Alimentary :-
 Food poison .
 Hematemesis
* Common cause of hematemesis :-
1) Gastric ulcer .
2) Duodenal ulcer .
3) Esophagitis , gastritis .
4) Varices of esophaguse .

5.  Dyponea - Sudden or gradual ?
 Character of breathing ? rapid , wheezing , labored , periodic .
 Degree of distress ? dose the patient collapse during attack ?
 Associated with cough , sweating , palpitation ?
 Is the patient free from symptom in between attacks ?
 Ask about the circumstance : after exercise & exertion or in the
bed ( orthopenoea ) .
* Common cause of dysponea :-
1) Aspiration of foreign body .
2) Pulmonary embolism & edema .
3) Respiratory causes like asthma .
4) Metabolic : uremia , D.M , salicylic acid poisoning .
5) Cardiovascular cases : heart failure .
 Cough - Frequency ?
 Severity ?
 Any special time for cough ?
 Aggravating factors ( dust , pollen ) .
 Dry or productive ? if productive : the amount , character , color
, smell of sputum ? , is there any blood in sputum ? , fresh , red
, dark brown , mixed with sputum or in a form of streak ?
* Common cause of cough :-
1) Sinuses :-
 Infection .
2) Larynx , trachea , airways :-
 Infection .
 Tumors : malignant , primary , secondary .
 Aspiration .
 Foreign body ; irritant dust .
3) Small airways :-
 Asthma .
 Chronic bronchitis .
 Irritant dust .
4) Alveoli :-
 Alveolitis .
 Drug ; ACE inhibitor
 Irritant dust .

6. * Type of sputum :-
Type Appearance Cause
Serous Clear , watery , forthy , pink Acute pulmonary edema , alveolar cell cancer
Mucoid Clear , grey , white , viscid Chronic bronchitis / COPD asthma
Purulent Yellow , green Pneumonia , lung abscess
Rusty Rusty , golden , yellow Pneumococcal , pneumonia
 Headache - Character of pain ( dull , throbbing & shooting ).
 Continuous or intermittent ? if intermittent :-  Duration and
frequency ?  Is related to any special time ?  Any aura ?
 Aggravating & relief factors ?
 Site of the pain .
 Associated symptom .
 Any history of head injury , hypertension ,loss of consciousness .
* Common cause of headache :-
1) Migraine .
2) Intracranial pressure .
3) Vasodilator drugs ( acute attack ).
4) Meningitis & encephalitis .
5) Sinusitis .
6) Refractive error of sight .
7) Intracranial hemorrhage .
 Mass - Site .
 Size .
 Number .
 Surface .
 Consistency .
 Mobility .
 Tenderness .
 Pulsation .
 Fluctuation .
 Is the skin over the mass ; mobile or fixed ?
 Is there any sing of acute inflammation ?
 Any sinus formation over the swelling ?

7.  Fits - Generalized or localized ?
 Frequency & duration .
 Any loss of consciousness ?
 Any history of sphincter control ?
 Any history of head injury ?
 Associated symptom : tongue biting , frothing from the mouth ,
deviation of eye ball .
 Any aura : anxiety , hungry , crying , fortification , headache .
 Dysphagia - Site
 Painful or not ?
 Progressive or intermittent ?
 For solid , liquid , both ?
 History of indigestion or regurgitation .
* Common cause of dysphagia :-
1) Oral :-
 Mouth ulcer & infection .
2) Neurological :-
 CVA .
3) Neurovascular :-
 Achalasia .
 Myasthenia gravis .
4) Mechanical :-
 Esophageal cancer .
 Peptic stricture .
 Weakness - Sudden or gradual ? if gradual ; what is the duration
 Generalized or localized ? what is the part if localized ?
 Grade of weakness .
 Associated symptoms : loss of conscious , fever , loss of sensation.
 When dose the patient feel weakness ? at rest or after prolonged
use of muscle ( myasthenia gravis ) ?

8. System of review :-
1. Exclude the system that involved in present illness .
2. You can use medical terms .
3. You can use leading questions .
A. Cardiovascular system
Question about it :-
 Chest pain Dysponea Edema
 Palpitation What bring it ? Duration Pulse
 Apistaxis bleeding under the skin
 Claudication pain in calf muscle in walking
B. CNS
Question about it :-
 Paralysis headache blurred vision diplopia
 Convulsion associated with loss of consciousness
 Any abnormal movement
 Vertigo continuous or paroxysmal ? severity
 Control of the sphincters , muscle weakness
C. Respiratory system
Question about it :-
 Cough what it's characters
 sputum what it's characters
 palpitation & leg swelling
 dysponea
 chest pain
D. Urogenital system
Question about it :-
 urine volume : ( polyuria , oligouria , retention , anuria , dysuria )
 frequency , incontinence & urgency
 nocturia : as in D.M , renal failure or UTI
 hematuria with pain or not
 burring micturation
 loin pain & it's radiation

9. E. GIT
Question about it :-
 Appetite
 Nausea
 Vomiting & it's characteristic
 Dysphagia : Type of food
 Salivation
 Heart burn
 Thirst
 Abdominal pain
 Abdominal distension
 Diarrhea
 Constipation
 Melaena : dark stool of indigested food
 Hematochaasia : fresh blood in stool
 Use of laxative
 Acidity
 Hematemesis
 Tinnismus : pain in defecation
 Flatulence
F. Locomotor system
Question about it :-
 Arthralgia :whish joint
 Myelgia & bone ache
 Disturbance of gait
 Deformity or any abnormality of skeletal system
 Joint swelling
G. Integumentary system
Question about it :-
 Rash : duration & associated with pain ?
 Hyperpigmentation
 Loss of hair & skin pigmentation
 Hair over growth
 Family history of skin disease

10. Past history :-
1. Medical history
This part include the chronic disease ………….
The patient is a known case :- diabetes mellitus , hypertension , ulcer , T.B , asthma ,
any previous hospitalization
2. Surgical history
Any operation in the past ( include any gynecological sex )
Drug history :-
Write if the patient on therapy
1) Antibiotic
2) Radiotherapy
3) Allergy to penicillin , aspirin , sulph drug
4) Psychotropic drug
5) Blood transfusion
6) Vaccination
7) Steroid
Menstrual history :-
Question about it :-
1) Age of the menarche
2) Age of menopause
3) Amount of blood loss
4) Amenorrhea
5) Abortion = fetal loss
6) Normal vaginal delivery = caesarian section
Family history :-
Question about it :-
1) No. of sister , brother , daughter , sons & there health .
2) Are the parent alive or not ? Are they relatives or not ?
3) Any familiar disease .

11. Personal & social history :-
Question about it :-
1) Smoker or not ?
2) Alcoholic or not ?
3) Any special habit ( bird collector ) .
4) Economic & nutritional state .
5) Living in large or small place ?
6) Water supplementation ( tab , river water )?
7) In rural urban place .
8) Is there any domestic animal ?
9) Level of education .
10) Martial state .
Summary :-
Name , age , sex , address , date of admission , chief complaint and brief explain of present
illness.