History Sheet

Name: ________________________________ Age: ___________ Sex: M | F

Occupation: ____________________________ Residence: ___________________________

Marriage state:__________________________ Smoking:_________________Habit:___________

Children:___________ and the youngest______________ Para/gravida/abortion:________________________

Menstrual History:_________________________________________________________________________

Presenting Complain ______________________________________________________________________

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 Symptoms of other systems Investigations
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Treatment
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Past Medical & Surgical History Family History

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NOTES
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Cardiology
Pulmonary congestion: Dyspnea – Cough – haemoptysis – Recurrent Chest infection Cyanosis

Systemic Congestion: Edema – Ascitis – Rt. Hypochondrium Pain – Jaundice – Dyspepsia

 CO: Syncope – Headache – blurring of Vision – Dizziness –– Oliguria – Muscle – Pallor – Anginal Pain Dyspnea – Sweating ?
Pressure manifestations: Brassy cough – Dyspnea – Dysphagia – Hoarseness of voice – Edema and Cyanosis
HTN: Fatigue – Headache – Blurring of vision – Tinnitus – Epistaxis Palpation Regular or irregular ?
Embolic Manifestation: Parathesis – Paralysis – Painless Haematuria – Abdominal Pain Fever

Chest
Cough: Wheezes – Hoarseness - Vomiting? Nocturnal – Early Morning – All Over the day – Seasonal ?

Haemoptysis: Type ? Blood Transfusion ?

Cyanosis
Expectoration: Postural Variation Amount – 3Cs – Odour Type ?
Dyspnea
Wheezes Continuous – Paroxysmal ?
Toxic M.
Systemic Congestion: Edema – Ascitis – Rt. Hypochondrium Pain – Jaundice – Dyspepsia

Pressure manifestations: Brassy cough – Dyspnea – Dysphagia – Hoarseness of voice – Edema and Cyanosis

Chest pain: Stitching – dull aching – throbbing - tearing ?

Abdomen
Upper GIT Appetite – Dysphagia – Vomiting – Haematemesis – Halitosis – Hiccough – eructation – heart burn ?

Lower GIT Flatulence – Intestinal sounds – Bowl Habit Changes – Haematochezia – Melena

Gynaecological manifestations Toxic M. Abdominal Swelling Abdominal Pain LL. Swelling

Hepatobiliary : Jaundice Pruritis Dyspepsia Pain

Urogenital Micturition Uraemic M. Sexual

Neurology
Cranial Ns
Motor system Weakness Involuntary movements 3+5+5 Co-ordination

sensory system Superficial Deep Cortical

Sphincter troubles Neurogenic bladder Motor – Sensory - Automatic

Speech troubles
Hypothalamic manifestations Sleep ? – Mood ? – Toilet ? – Eating ?

ICT symptoms
Haematology
 RBCs Headache – Blurred of vision Anginal pain - Dyspnea - Palpation Fatigue – Syncopal Attacks

 WBCs  Infections ?

Bleeding Per orifices Skin lesions

Jaundice OCD Urine - stool Anorexia – Nausea – Vomiting Fever – Bleeding – Pain – Purities

RES Hyperplasia HSM LNs++

Thrombosis manifestations

Cushing
Metabolic DM  Fat Ms weakness – Striae – Purpura

Bone Marrow Plethoric face Cyanosis with cold

Infections?
Androgen like action Acne - Hirsutism

Sensitivity to catecholamines  BP

 Gastric mucous secretions Epigastric pain and tenderness

Hyperthyroidism

Pain analysis swelling analysis: OCD – site – size – shape – consistency – surface – skin over it
Pressure manifestations: Dyspnea – Dysphagia – Hoarseness of voice

Toxic manifestations