@MD1TALK

History
Personal data:
1) Name
2) Age
3) Sex
4) Nationality
5) Residence
6) Martial status
7) Date of admission
8) Mood of admission / Mood of transfer
9) Handedness
c/c with duration
Patient words +
Max is 3

HPI 1-analysis with SOCRATES (for pain) or OD PARA

CARE (anything other than pain)
Onset
Duration

Progression
Aggravating
Reliving factor
Associated symptoms

Course:
- Timing (all day, night, morning or recurrent ) - Severity via: affecting (sleep,
eating, activity) - related to speci c food or activit
Another: if the Sx contain uid → (COPA PC)
Color , Odour , Presence of blood or pus, Amount , related to Position ,
Character

Risk factors:
Else:

2-constitutional Sx: weight loss, fevers, anorexia, night

sweating
3-hospital course (improved or deteriorating - transport in
hospital
4-Sx of the system involved

fl
fi

 @MD1TALK

ROS CNS 🧠 1) headache

2) weaknes
3) blurry vision
4) dizziness
5) abnormal movement
6) loss of consciousness
7) Tinnitus

CVS 🫀 LEFT SIDE HF

• orthopnea
• PN
• Dyspnea
RT SIDE HF:
• lower limb swelling
• early satiety
Central ischemia:
• chest pain → yes ?→ SOCRATE
Peripheral ischemia:
• claudication →yes? → when does it start, how
KM, with rest improve
Electrical:
• palpitation

RES 🫁 1-Cough 2-sputum (COPA PC analysis)

GI 🤢 1)
2)
Abdominal pain
Dysphagia
3) Vomiting and nausea and hematemesis
4) Constipation , diarrhea
5) Melen
6) Jaundic
7) Heartburn

Renal 🍺 1)
2)
Loin pain
Oligo/poly-uria
3) Dysuria
4) Hematuri
5) Frequency, Urgency, Nocturia (FUN)

MSK 🦴 1)
2)
Joint pain
Rash
3) Pigmentation
4) Muscle pain

Surgical: MEDICAL:
PH 1) Previous surgery ? 1. similar conditions (when, how many?
(when where why 2. chronic illnesses: when, where, how he was
2) Traum dx, controlled or not
3) Blood transfusion • DM, ASTHMA, HTN, Hyperlipedemia
3. hospital admission : Number? Duration ?
D

 @MD1TALK

Menstrual Hx 1) Age of menarche

2) Regularity of mense
3) Last Menstural Period (LMP
4) Hx of painful menses or menorrhagia
5) OCP use
Immunizations + If immunnocmpramized or with sickle cell anemia
history of contact
with infected
individual

SH 1) Smoking or alcohol or extra-martial relationships (take permission

rst
2) Occupation and income
3) Travel H
4) Pets at house
5) House conditions
6) Change in the mood in the last 2w

FH 1) Similar condition in family

2) Chronic illness in family
3) Inherited disease in family
4) Allergy in family

DH 1) current TT
2) Past TT
3) over the counter TT
4) herbs and vitmans

name + route + dose Indication + frequency Side effects + recent

change in dose

Allergy To food or drug ?

ICE I: ideas (thoughts C: concerns: E: Expectation

regarding symptoms) E: Effect
ANYTHING YOU WANT TO ADD?

Summary
……year old …… known case of/medically free ………… present to the
……….and complain …….c/c………
(+) ndings
(-) ndings: only if it’s importan
Hospital course
fi
fi
)

fi
T

@MD1TALK

Examination
———————————————————————————————————————————
———————————————————————————————————————————
———————————————————————————————————————————
———————————————————————————————————————————
———————————————————————————————————————————
———————————————————————————————————————————
———————————————————————————————————————————
———————————————————————————————————————————
———————————————————————————————————————————
———————————————————————————————————————————
———————————————————————————————————————————
———————————————————————————————————————————
———————————————————————————————————————————
———————————————————————————————————————————
———————————————————————————————————————————
———————————————————————————————————————————
———————————————————————————————————————————
———————————————————————————————————————————
———————————————————————————————————————————
——————————————————————————————————————————

Lab:
———————————————————————————————————————————
—————————————————————————————————————————

Assessment and plan :

———————————————————————————————————————————
———————————————————————————————————————————
———————————————————————————————————————————
—————————————————————————————————————————
—