Patient Profile:
[Name, Age, Sex, Marital status, Occupation, Address, Admission, Setting]
History of Present Illness:
Chief Complaint and Duration: Analysis: > Analyze the CC: > The Cause: > Management: > Review the involved System: System Review:
Past History:
Similar Attacks. Disease in the same system. Chronic illnesses. > DM, HT, Asthma. > Bleeding tendency. Acute illnesses in the past. > MI, UTI Hx of Trauma: [Surgical/Accidental] Blood Transfusion Recent travel
History of Allergy:
Food, Drugs, Pollens.
Drug History:
Current Drugs. Insulin, Steroids, Antidepressant, OCP. Drugs over the counter. [,,,]
Family History:
Diseases in the involved system. Anything else.
Socioeconomic History:
Bad Habits Income, Insurance. Anything Else.
System Review: General Symptoms:
Weight change. Loss of Appetite Why? Fatigue, sleeping ,
Musculoskeletal System:
Joint pain, swelling, limitation of movement.
Endocrine System:
Heat / Cold intolerance. Excessive sweating.
Cardiovascular System:
Chest Pain. Palpitation. Wake up during night. [Orthopnea, PND] Difficulty in Breathing. Ankle swelling or Leg Edema. Intermittent claudication.
Neurological Symptoms:
Dizziness, Headache, Loss of consciousness. Blurred Vision, Hearing problem. Memory & Concentration change. Numbness and weakness in the limbs.
Analyze The Symptoms: Respiratory System:
Respiratory System:
Shortness of Breath. Cough. Sputum. Hemoptysis. Audible Breath Sound. Chest pain.
Cough:
Acute / Chronic. Sound: Dry, wet, Wheeze, Hoarseness. Timing: Day, Night, Work, Swallowing
Alimentary Tract:
Mouth ulcers. Dysphagia, Heart burn. Nausea & Vomiting. Hematemesis. Abdmominal Pain & Distension. Any Change in the bowel Habit. Change in the color of the stool. Melena, hematochezia.
Sputum: amount, color, smell, solid material. Hemoptysis: amount, Appearance, Duration & Freq. Chest Pain: SOCRATES, Related to Cough or Insp. Breathlessness SOB:
Onset, Duration and Progression. Agg. & R. Factors: Lying, PND, Pollen, Drugs, Smoke. Severity: Walking flat VS walking uphill. Associated Sx: Chest pain, Cough, Wheeze.
Apnea:
Heart Symptoms:
Chest pain & Discomfort:
SOCREATES & Duration. Related to Inspiration, movement? Nausea & vomiting.
Genitourinary System:
Urinary symptoms: Irritative Symptoms: > Frequency, Urgency, Incontinence, Nocturia.
> Burning on Micturation.
Breathlessness SOB
Same as RS. Orthopnea, PND # of Pillows.
> >
Obstructive Symptoms:
Hesitancy, Intermittency, Dripping, Poor Stream. Straining, incomplete Voiding, Retention.
Palpitation:
Onset & Termination [Sudden or Gradual] Frequency and duration. Preci. factors: [Exercise, Coffee, Drugs, Joy, Smoking ] Relieving factors: [Breath holding, Exercise]
Change in the color & the smell of the urine. Thirst, Edema Uremia: (headache, drowsiness, visual disturbance) Female menstrual period:
> Regular, Prev. menses, amount, Pain.
Syncope & Dizziness: Describe what happened
Preci. Factors: [Head turning, getting up, the dose]
Edema:
Site : [Ankle, Lower limb, Sacral area ]
Alimentary Tract:
Dysphagia:
Since? Solid or Liquid. Pain, Heart burn, Choking.
Heart Burn:
Site & Radiation Acid reflux? Related to lying flat or bending.
Nausea and/or Vomiting:
Pallor, Sweating, Hyperventilation. Related to food or posture. Amount, color, content. Abdominal pain, Drugs, Pregnancy. Hematemesis: [Fresh or Coffee ground]
Abdominal Pain: SOCRATES Abdominal Distention:
Onset. Constant or Variable. Pain or affecting Respiration. Relieved by?
Change in Bowel habit:
Frequency & consistency. Tenesmus.
Rectal bleeding & Melena:
Melena: Iron sup., NSAIDs, ate something, alcohol. R. Bleeding: Mixed, on the surface or on the T. paper.
Jaundice:
Stool & urine color. Skin itch, abdominal pain.