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- 1. S2MART HISTORY History Form ABSTRACT History taking, its components i.e Bio-data, Present complaint, History of Present Complaint, Systemic review, Past History, Drug history, Immunization History, Family history, Socio-economic history, Personal history. Manzoor Hussain Final year Medical Student
- 2. S2 MART History Form Bio Data Name :__________________F/H Name:__________________ SEX:_________ Age:__________ Marital Status:_____________________ Occupation:__________________________________ Address:_______________________________________________________________________ Date of Admission: ______________ Mode of Admission: _______________ Bed No: ________ Ward No: _______________ Date of Examination: ___________ Co/Morbidity:_____________ Present Complaint/ Chief Complaint: ( Listed in order of Severity ) Complaint: ____________________________when it start____________ How it Start________ Complaint: ____________________________when it start____________ How it Start________ Complaint: ____________________________when it start____________ How it Start________ History Of Present Complaint: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
- 3. Systemic Direct Inquiry: Alimentary System: Appetite: Increased/decreased/remain unchanged____________________________________ If decreased (lack of desire to eat or eating cause pain)_________________________________ Diet: Veg/Non veg:__________ Time: B/F________ Lunch___________ Dinner______________ Weight: Increased/decreased______ How much_____ How long______ How they know______ Teeth: Can they chew their own food___________ Do they have their own teeth____________ Taste: Odd Taste____ Sensation in mouth_________ Water brash________ Acid brash_______ Swallowing: Dysphagia: _____ Solids:____ Liquids:_____ Level of obstruction:______________ Duration____________ Progression:_________________ Odynophagia :___________________ Regurgitation: Yes/Not:_____ What comes Up:_________ If Food ? Digested_______________ Recognizable________ Or Undigested________ How often does it occur __________________ Precipitating factor:__________(Stooping/Straining). Flatulence: Frequency __________________ Relation to any other Symptoms:______________ Heart Burn: How often does it occur______________ How it happen: Lying flat_____________ Bending over__________________. Vomiting: How often do they vomit?_____________ Is the vomiting preceded by nausea?_____ Projectile/Non Projectile_______________ Volume of Vomitus_____________ Nature: Food from previous meal/Digested food/clear acidic fluid/bile stained fluid?_____________________ Preceded by any other symptom: Indigestion pain/Headache/Giddiness?___________________ Does it follow eating?____________________________________________________________ Hematemesis: Yes/Not________ Recent Nose bleeding ________________________________ Indigestion/Abdominal Pain: Discomfort after eating_______ Pain after eating______________ Site of pain______________ Time of onset_____________ Severity______________ Nature of pain____________________ Progression_______________________ Duration______________ Radiation______________ Course__________________ Precipitation factor________________ Exacerbating Factor___________________ Relieving Factor_____________________________. Abdominal distension: Yes/Not?______ How they know?_______________ When it occur and how has Progressed?__________________________ Is it constant/Variable?_______________ Which factor causing variation?__________________ Is it painful?_____________ Does it affect breathing___________ Is it relieved by belching/vomiting/defecation?_______________ Defecation: How often does the patient defecate?____________________________________ Color of stool ( Brown/Black/Pale/White/Silver)_______________________________________
- 4. Consistence:(Hard/Soft/Watery ___________ Size:(Bulky/Pellets/String/Tapelike____________ Specific gravity:(Float/Sink)_______________ Smell?___________________________________ Rectal Bleeding: Yes/Not?_______ Bright/Dark?__________ How much?__________________ Mixed in stool / On the surface of stool / Appear after passing stool?______________________ Flatus/Mucus/Slime/Pus:__________________________________ Is defecation Painful?(if yes when it start before/during/after/at times unrelated to defection)________________________ Prolapse and incontinence: Does anything comes out of anus (if yes reduce spontaneously/ manually?) ______________________ Is the patient continent of feces/flatus?______________ Has the patient had any injuries/ anal operation in past?________________________________ Tenesmus: Do they experience any urgent, painful but unproductive desire to pass stool?_____ Change of skin color: Jaundice?(if yes then when and how long it remain)__________________ Were there any other accompanying symptom such as abdominal pain/ loss of appetite______ ___________________________ Did the skin itch?____________________________________ The Respiratory System: Cough: How often does the patient cough?__________ Does cough comes in bouts?_________ Precipitating/Relieving Factor (i.e Change of posture )____________ Dry/Productive?________ Sputum: Quantity _________ Color____________ Special time/Posture of occurrence________ Hemoptysis: Yes/Not?__________ Is it Frothy/and pink?____________ Were there Red streaks in mucus/Clots of blood?________ Quantity__________ How often it occur?_______________ Dyspnea: Wheeze?________ Breathless?_________ How many stairs can he climb?_________ How far can he walk?_______ Can he walk and talk at the same time?_____________________ Is Dyspnea present at rest?_____ Is it present when sitting or made worse by lying down?_____ Orthopnea?________ Number of pillow at night?__________ Does the breathlessness wake up at night / get worse if they slip off their pillows?_____________ Is the dyspnea induced or exacerbated by external factors such as allergy to animals, pollen or dust?_________________ Does dyspnea occur with both phases of respiration or on expiration?_____________________ Pain in the chest: Site_______________ Severity_________ Nature_______________________ Chest pains can be continues, pleuritic (made worse by inspiration), constricting or stabbing.
- 5. The Cardiovascular System/Cardiac Symptoms: Breathlessness:________ Orthopnea:___________ Paroxysmal nocturnal dyspnea:_________ Pain: Cardiac Pain: Site ( usually mid-line/retrosternal/epigastric)_________________________ Nature: ( Usually constricting/ band-like)___________________ Increase by exercise_________ increase by excitement:_____________ Radiation: ( Neck/Left arm)__________ Is it relieved by rest?_____________________________ Palpitation: ________________________ Ankle swelling( Ankle/leg)_______ when do they swell?_____________ Effect on the swelling of bed rest/leg elevation?____________________ Dizziness/Headache/Blurred Vision?________________________________________________ Peripheral Vascular Symptoms: Does the patient get pain in the leg muscles on exercise?_______________________________ Which muscles are involved? ______________________________________________________ How far can the patient walk before the pain begins?___________________________________ Is pain so bad that he has to stop walking?____ How long does the pain take to wear off?_____ Can the same distance be walked again?_____ Is there any pain in the limb at rest?__________ Which part of limb is painful?______________ Does pain interfere with sleep?______________ What positions relieve the pain?________________ Drugs relieve pain?___________________ Extremities of limb cold?__________ Change of color in response to cold?_________________ Paranesthesia in the limb ( tingling/numbness)? ______________________________________ The Urogenital System Urinary Tract Symptoms: Pain: Site:______________ Nature:_____________ Severity:__________ Radiation?_________ Oedema: _____________________ Thirst: Thirsty?_____ Drink Excessive water?____________ Micturition: How often does the patient pass urine?(Day/Night ratio:) ____________________ How much Urine is passed?(Volume and Frequency)___________________________________ Is micturition painful?________ Nature of pain?_________ Site of pain?___________________ Is there any difficulty with micturition ( Strain/wait)____________________________________ Is the stream good?__________ Can he stop at will?_________ Dribbling at the end?_________ Does bladder feel empty at end or have to pass urine 2nd time?___________________________ Urine: Hematuria ?___________ When and how often?________________________________ Pneumaturia(Gas bubbles with the urine)?___________________________________________ Symptoms of Uremia: Headache?________ Drowsiness?_______ Visual disturbance?_____ Fits and Vomiting?______
- 6. Genital tract symptoms: Male: Scrotum, Penis and Urethra: Pain in penis/urethra during micturition/intercourse?__________________________________ Any difficulty with retraction of prepuce or any urethral discharge?_______________________ Scrotal Swelling ?____________ Can he achieve erection and ejaculation?__________________ Female: Menstruation: Menarche age ?_____________ Menopause age ?________________________ What is the duration and quantity of menses?________________________________________ Dysmenorrhea ?__________ Nature of pain?__________ Severity of pain?_________________ Is there any abdominal pain mid-way between the periods(Mittelschmerz)?________________ Has the patient had any vaginal discharge (if yes what is character and amount)?____________ Has she noticed any prolapse of vaginal wall/cervix/any urinary incontinence, especially when straining or coughing(stress incontinence)?___________________________________________ Pregnancies: Details?____________________________________________________________ Number/Dates/complications of pregnancies?________________________________________ Dyspareunia: Is intercourse painful?________________________________________________ Breasts: Any change during menstrual cycle?_________ Are they ever painful/tender?_______ Has the patient noticed any swelling or lump in the beast?______________________________ Does she breast feed her child?_____________ Has there any nipple discharge?_____________ Has she noticed any skin changes over the breast?____________________________________ Secondary Sex Characteristics: When did they appear?________________________________ The Nervous System Mental State: Is the patient placid or nervous?________________________________________ Is there any behavior changes? (Ask from close relative):________________________________ Is patient get depressed and withdraw?______________________________________________ Are they excitable and extroverted?_________________________________________________ Brain and cranial nerves: Does the patient ever become unconscious/have fits?_____________ What happens during fits? ( ask from relative or bystander about fits)_____________________ When was the last episode of fits had occurred________________________________________ Was he/she fall down on flat/Rough/Soft (sofa/comfortable ) surface______________________ Did the patient lie still/jerk about/bite their tongue/pass urine?__________________________ Was the patient sleepy after fits?______ Was there any aura?___________________________ Any subsequent change in the senses of smell, vision and hearing?________________________
- 7. Is there a history of headache?_____________ Where is it experienced?___________________ When does it occur?_____________ Association with any visual symptom?_________________ Has the face ever become weak/paralyzed?__________________________________________ Have any of the limbs been paralyzed or had pins and needles?__________________________ Has there ever been any buzzing in the ears, dizziness or loss of speech?___________________ Can the patient speak clearly and use words properly?__________________________________ Peripheral Nerves: Are any limbs or parts of a limb weak/paralyzed?______________________ Is there ever any loss of cutaneous sensation?________________________________________ Does the patient experienced any tingling ’pins and needles’ in limbs?_____________________ Musculoskeletal System: Pain?______ Time of Onset_______ Nature/Severity:________ Precipitates/relieved by:______ Swelling?_________ Time of onset_________ Precipitates/relieved by:____________________ Limitation of movement in any joint?________ Onset_______ Precipitates/relieved by:______ Are any limbs or group of muscles weak or painful?____________________________________ Can he walk normally?__________ Any congenital musculoskeletal deformities?____________ Previous history of other illness, accidents or operation: Any Chronic illness?_____________________________________________________________ Any previous illness/treated disease?_______________________________________________ Any previous illness for which he/she admitted in hospital?____________________________ Any operation in past?________________ Any Accident in past?_________________________ Tuberculosis?____________ How long?____________ Treated/Not?_____________________ Diabetes?_______________ How long?______________ Under medication/Not?____________ Rheumatic fever?________ How long?__________ Treated/Not?________________________ Allergies?_______________ From which thing?__________ In which season?_______________ Asthma?______________ How long?__________ Under medication/Not?_________________ Ask about tropical diseases/Bleeding tendencies/Diphtheria/Gonorrhea/HIV?_______________ Drug History Steroids?___________ Anti-depressant?___________ Insulin?_________ Diuretics?_________ Anti-hypertensive?_________________ HRT?_____________ Oral contraceptives?__________ Sensitivity to any drug?___________________________________________________________ Immunizations In neonatal age is he/she vaccinated or not?_______ Is he/she vaccinated for : Diphtheria ____ Tetanus________ Whooping cough_______ Measles_______ Mumps_______ Rubella________ Poliomyelitis_________ Small pox________ Typhoid_________ Tuberculosis_______________.
- 8. Family History Health/Age/Cause of death of family members: _______________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Ask about children who have died?_________________________________________________ If the patient is child: Ask about mother’s pregnancy___________________________________ Did She take any drugs during pregnancy?____________________________________________ What was the birthweight of patient?____________ Mode of delivery?____________________ Any difficulty during delivery?_____________________________________________________ Rate of physical and mental development in early life?_________________________________ Social History Martial status:_______________ Type and place of dwelling?___________________________ Occupation__________________ Extra Activities?____________________________________ Has patient travelled abroad?_________ Country name and date of visit?_________________ Habits/Personal History Smoking?____ Cigarettes/Cigar/pipe?______ Frequency_____ Quantity______ Duration______ Drinking?__________ Type_______________ Quantity___________ Duration______________ Unusual eating habits?_________ Sleeping?__________ Micturition/Bowel habits?_________ Formulated by : Manzoor Hussain Narejo Final year Medical Student Ghulam Muhammad Mahar Medical College Sukkur Batch number :14th Email: manzoorhussainnarejo786@gmail.com Reference: Norman L.Browse, John Black, Kevin G.Burnand and William E.G.Thomas
- 9. Reviewed by: Ahsanuallah Junejo Final Year Medical Student Ghulam Muhammad Mahar Medical College Sukkur Batch number: 14th Awais Ali Channa Final Year Medical Student Ghulam Muhammad Mahar Medical College Sukkur Batch number: 14th Rehman Ali Solangi Final Year Medical Student Ghulam Muhammad Mahar Medical College Sukkur Batch number: 14th Tousiq Ahmed Malik Final Year Medical Student Ghulam Muhammad Mahar Medical College Sukkur Batch number: 14th Sajjad Ali Ghumro Final Year Medical Student Ghulam Muhammad Mahar Medical College Sukkur Batch number: 14th Saadat Abbas Mahar Final Year Medical Student Ghulam Muhammad Mahar Medical College Sukkur Batch number: 14th Muhammad Ayoub Phulpoto Final Year Medical Student Ghulam Muhammad Mahar Medical College Sukkur Batch number: 14th Manzoor Hussain Narejo Final Year Medical Student Ghulam Muhammad Mahar Medical College Sukkur Batch number:14th