HISTORY

INTRODUCTION
· Good Morning, I am ----------, Clinical Clerk from UNP. I would like to ask few ques-
tions Po.
GENERAL DATA
· May I know your name Po?
· Age
· Sex
· Date Of Birth
· Civil Status
· Occupation
· Nationality
· Religion
· Is this your Ist Hospital Visit
· Reliability
· Informant
CHIEF COMPLAINT
· What made you to seek Consult?
HISTORY OF PRESENT ILLNESS (OPQRSTAS)
· LOCATION –in which ear do you feel the discomfort
· ONSET- (When did you start experiencing this?)(Started experiencing long time ago
or Sudden?)
· PRECIPITATING FACTOR – Do you have Hearing impairment? Conductive
loss? – Environmental NoiseSensorineural loss – trouble understanding speech, hear-
ing worse
· PALLIATING FACTOR – Have you done anything to relieve the pain?(Relieving
Factor)
· QUALITY – Can you describe your pain? What is it like? ((i)Dull (ii)Burning
(iii)Sharp (iv)Steady (v)Cramping (vi)Colicky Pain (vii)Pinpoint (Musculoskeletal
Pain) (viii)Localised/Generalised)
· RADIATION – Does it radiate anywhereelse? Did it travel anywhere else?
· SEVERITY – If you rate your pain in the scale of 10, what will be your scoring?
(Consider 1 being less severe and 10 being the most severe)
· TIMING – Frequency? Duration?
❖ What time of the day do you experience this?
❖ How long does it last?(Duration)
❖ How often do you experience this in a day? (Frequency)
· ASSOCIATED SYMPTOMS – have you noticed anything else that accompanies
your symptom like Associated Fever? Sore throat? URTI? Tinnitus? Vertigo? Dizzi-
nesss? Headache? Swelling? Any Discharge?
o Onset /Duration
 o How
o Continuous and Intermittent
o Progression
o Amount
o Color Organism
o Consistency Serous, Mucoid, purulent
o Odor
o Blood discharge
o Aggressive Factor
o Relieving Factor

COURSE OF ACTION (Based on the Chief Complaint)

· Number of admissions in the hospital?

· Was any consult sought before?

o If YES Is there any medications taken?(with dose)
o Does it cured/relieved?
· Is there any Non prescribed drugs, home remedies, supplements taken?
PAST MEDICAL HISTORY
· Childhood
o Have you had any illness in childhood?
o What was the age when you had the illness?
o (Measles, Mumps, Rubella, Poliomyelitis, Varicella, Pertussis, Rheumatic
Fever, Scarlet Fever)
· Adult
o Do you have any other medical problems?
o When were you diagnosed with this condition?
o What were your treatments?
o You have Allergic Problems?
o HPN, Stroke, Renal, Asthma, TB, DM, Cardiac, GI, STD, Others
o Jaundice or any liver related problems, Anaemia or any hematologic disor-
ders, Myocardial Infarction, Epilepsy, Dislipidemia
· Surgical
o Did you undergo any surgeries?
o What type of surgery?
o What year was the surgery?
o Why was it performed?
o Did you experience any complications after surgery?
· Psychiatry
 o (i) Have you had any psychiatric consult before?
If YES (i) what is the reason for consult?
(ii) Were you given any medication there?
· IMMUNIZATION
o Have you taken Immunization (Vaccine)
FAMILY HISTORY
· Family members?
· How are your Parents? Are they healthy?
· Does any of your family members have any medical conditions?
Like
o Hypertension
o CAD (Coronary Artery Disease)
o Cholesterol
o Asthma (Lung Problems)
o Headache
o DM (Diabetes Mellitus)
o TB
o Stroke
o Arthritis
o Thyroid Disorder
o Asthma
o Cancer(Breast, Ovary, Colon, Prostate)
o Seizure
o Allergies(Peanut)
o Mental Illness
o Renal Problems
o Arthritis
o Any suicide?
o Substance Abuse
o Genetic Disease
PERSONAL AND SOCIAL HISTORY
· Your Educational attainment?
· What is your occupation and may I know about your working environment? (working
hours)(Current and Past)
· It’s been how many years you married?
· You have children? How many children you have?
· HOUSE
o Type
o Rooms
o Bathrooms
 o Ventillation
o Pets
o Environment
o Water Source
o Garbage disposal
· Do you exercise regularly?(Hours/day)
· May I know your usual diet Plan? How many meals/day? Is there any diet restric-
tions?
o Do you drink coffee, tea, soda?
· Smoking
o Non, current, Ex
o Sticks/packs per day
o Year started
o Year quit?
· Alcohol
o How often you drink? (Never, Occasionally, Daily, Weekly)
o What Type of alcohol you drink? (Gin, Beer)? How many glass?
· Have you ever been on illicit drugs? When? Stopped?
· Do you recently travelled anywhere? (where)

REVIEW OF SYSTEMS
(Next part will feel like some more questions, but it is necessary to ask we don’t missed any -
thing.)
(Just respond YES/NO for the following questions)
GENERAL
o Weight loss/Gain (do you find any change of size of the cloth you wearing?)
o Easy Fatigability (Do you feel tired easily?)
o Fever, Chills, Night sweat?
SKIN
o Have you ever had any skin changes?
o Any Rashes?
o Any Lumps?
o Pallor (Anemia)
o Unusual Hair loss
o Pruritus (Itching)
o Skin Dryness?
o Yellow Skin? (Jaundice)
HEENT
HEAD
 o Any discomfort in your head?
o Any head injury? (Trauma)
o Headache?
o Dizziness
o Lightheadedness
o Syncope
o Tenderness
EYES
o Do you have any problems with your eye/vision?
o Redness/Inflammation
o Eye discharge
o Excessive Tearing (Lacrimation)
o Pain
o Double vision (Diplopia)
o Use of glasses/Lenses
o Eye dryness
o Blurred Vision
o Photopsia (Flash light)
o Peripheral Vision
EARS
o Any hearing Problem?
o Hearing Loss?
o Pain
o Discharge
o Itching
o Tinnitus
o Dizziness
NOSE
o Any problem with your smelling sensation?
o Nasal pain
o Rhinorrhea
o Congestion
o Itchiness
o sneezing
o
MOUTH &THROAT
o Any problem with your mouth?
Like
▪ pain
 ▪ ulcer
▪ dryness
▪ Bleeding Gums
▪ Toothache
▪ Mouth Sores
▪ Sore Throat
▪ Dysphagia (difficulty in swallowing)
▪ Odynophagia(Painful swallowing))

NECK
o Any neck problem like (Pain, Lump, Stiffness)
RESPIRATORY
o Cough? (Sputum, Colour, Quantity)
o Haemoptysis (Spitting Of Blood)
o Wheezing or Asthma Problems (Bronchitis)
o Dyspnea (Shortness Of Breath)
CARDIOVASCULAR
o Chest Pain?
o Orthopnea (Any sensation of breathlessness in the recumbent position, re-
lieved by sitting or standing?)
o Cyanosis
o Palpitations
o Edema
o Paroxysmal nocturnal dyspnea (Any condition that triggers sudden shortness
of breath during sleep)
BREAST
o Have you experienced any changes in the Breast?
Like (Colour, Discharge, Lumps, Pain)
GASTROINTESTINAL
o Loss of Appetite
o Nausea
o Vomiting (Projectile, Color (to know bile content included), food particles)
(Hematemesis – Vomiting Blood)
o Abdominal Pain
o Hematochezia (Blood in Stool)
o Hemorrhoids (piles - are swollen veins in your anus and lower rectum)?
o Ulcer
 o Diarrhea (Colour, Consistency)
o Constipation
o Tenesmus ( feeling that you need to have a bowel movement)
o Melena (Melena - black, tar-like, sticky stools and usually results from upper
gastrointestinal bleeding.)
URINARY/RENAL
o Dysuria (Painful Urination)
o Nocturia (Tendency to urinate at Night)
o Incontinence (Lack of voluntary control over Urination)
o Urinary Urgence?
o Polyuria (excessive urination beyond normal?)
o Gross hematuria (Blood in urine?)
o Urinary retention (condition in which your bladder doesn't empty completely
even if it's full and you often feel like you really have to urinate)?
o Tea colored Urine? (Kidney disease/failure or muscle breakdown)
GENITALS
o Pain
o Discharge
o Swelling
o Itching
HEMATOLOGIC
o Easy Bruising
o Pallor
o Bleeding
ENDOCRINE
o Edema
o Polydipsia (feeling of extreme thirstiness)
o Heat/Cold Intolerance
o Polyphagia (excessive or extreme hunger)
o Excessive Sweating
EXTREMITIES
o Any Problem with your legs and Upper Limbs?
MUSCULOSKELETAL
o Any problem with your muscles and Bones?
o Pain
o Swelling
o Redness
o warmth
 PSYCHIATRIC
o Nervousness
o Anxiety
o Depression
o Hallucination
NEUROLOGIC
o Paralysis
o Tremors (Unintentional and uncontrollable rhythmic movement of one part or
one limb of your body)
o Memory loss
o Numbness (feels tingling or a loss of sensation (Pin/Needles))
o Seizure
PHYSICAL EXAMINATION
Let’s Proceed to some Physical Examinations
I. General Survey Inspect
o Mood Palpate
o Distress/Unusual position Percuss
o Cooperative non cooperative
o Irritated agitated pleasant
o Coherent
o Oriented to time and space
o Personal hygiene
o Level of consciousness- alert, drowsy, confused

II. Vital Signs

o BP
o HR
o RR
o Temp
o Sp O2
o Height
o Weight
o BMI

III. Skin: (Inspect &Palpate)Pallor, jaundice, cyanosis, rashes, hypo/hyperpigmentation,

clubbing, nail dystrophy

IV. HEENT
o Head- normocephalic / deformed
● Hair,- color? Fine? Coarse? Dry ? Hair loss?
 ● Scalp- dandruff? Lice infestation?
● Skull - lumps ? Lesions? Tenderness on palpation?
● Face- intact facial sensation for pain and temperature ? Face symme-
try? Facial expressions intact - able to smile, wrinkle forehead, puff
cheek ? Clench teeth?
o Eyes
● Acuity
● Visual fields
● Accommodation
● Confrontation
● Conjunctiva (color and discharge)
● Sclerae (color and discharge)
● Cornea (clarity, corneal arcus)
● Lids
● Position of eyes in orbits and alignment of the Eye
● Pupils
▪ Size R/L
▪ Shape
▪ Symmetry
▪ Accommodation
▪ Light reflex (PERLA)
▪ EOM
▪ Visual field
● Direct reaction
● Consensual reaction
● Fundoscopy
▪ Red orange reflex
▪ Disc
▪ Macula
▪ Blood vessels
o Ears
o INSPECTION: Inspect Pinnae, Mastoid, Pre-auricular area, skin color, defor-
mities Inspect ear for wax, discharge, foreign body, swelling, redness etc..
How to hold ear?- ADULT – PULL PINNA UP AND BACK INFANTS –
DOWNWARD
● Tenderness
● Hearing impairments
● Presence of hearing aids
● Weber test- Place the base of a struck tuning fork on the bridge of
the forehead, nose, or teeth. In a normal test, there is no lateralization
of sound. With unilateral conductive loss, sound lateralizes toward af-
fected ear (due to middle ear effusion after an upper respiratory tract
infection or acute otitis media). With unilateral sensorineural loss,
sound lateralizes to the normal or better-hearing side (due to Menière's
disease and cerebellopontine angle tumors)
● Rinne test -
 ▪Test compares air and bone conduction hearing.
▪Strike a 512 Hz tuning fork softly.
▪Place the vibrating tuning fork on the base of the mastoid bone.
▪Ask client to tell you when the sound is no longer heard.
▪Note the time interval and immediatly move the tuning fork to
the auditory meatus.
▪Ask the client to tell you when the sound is no lonnger heard.
▪Note the time interval and findings
▪Normal hearing clients will note air conduction twice as long as
bone conduction
▪With conductive hearing loss, bone conduction sound is heard
longer than or equally as long as air conduction
▪With sensorineural hearing loss, air conduction is heard longer
than bone conduction in affected ear, but less than 2:1 ratio
• Schwabachs test:
• he examiner sets the implement into lightweight vibration by pinching the
prongs between the thumb and index or by tapping it on his or her knuckles
• The ear not being tested ought to be disguised from sleuthing sound by bone
conduction by providing a sound stimulant into it throughout procedure
• The turning fork is command by its stem on the mastoid bone of the client,
who is taught to point whether or not the tone is detected. When he or she hears
the tone, the implement is quickly transferred to the mastoid bone of the exam-
iner, who listens for the tone
• This method continues back and forth between the client and also the examiner
till the tone is not any longer detected by one in all them, and also the results are
recorded. the method is then continual within the different ear
• Normally - bone conduction is same for the examiner and patient
• In conductive hearing loss- bone conduction is better than examiner
• In sensorineural hearing loss- bone conduction less than examiner

OTOSCOPY: To see Tympanic membrane

Hold Otoscope like pen – left ear – use left hand, right ear – use right hand
• Normal Color Shiny pearly gray and translucent
• Cone of light reflex in the antero-inferior quadrant (Right 5 o'clock, Left 7
o'clock)
• Pars Tensa, Pars Flaccida
• Annulus
• Malleus- umbo manubrium,short process of malleus

Nose
● Symmetry
● Frontal, maxillary sinus tenderness
● Obstruction
● Congestion
● Lesions
● Exudates
 ● Inflammation
• Note any nasal tenderness? Asymmetry? Deformity? Nasal obstruction? Skin color?
• Check with otoscope. Insert gently into the vestibule and avoid touch to septum (sensitive)
• See nasal mucosa - Virus Rhinitis – red & swollen
• Allergic rhinitis – Bluish, Red
• Check nasal mucosa— if deviates, Inflammation?
MOUTH, THROAT AND NECk
● Lips
● Teeth/dentures
● Gums
● Tongue
● Pharynx
▪ Lesions
▪ Exudates
▪ Erythema
• Lips, oral mucosa - good light and tongue blade
• Gum, tooth- if loose
• Tongue - Ask to protrude tongue out- deviated in CN12
• Pharynx - say’AH’- usually deviates - CN10
• Neck - check lymph node- tender- Inflammation
• Hard/Fixed - malignancy
• Trachea & Thyroid - Ask patient to swallow see movements of thyroid. Check symmetry
• Symmetry
• Limitation of ROM
● Tenderness
● JVP
● Lymph nodes
▪ Size
▪ Mobility
▪ Tenderness
▪ Borders
▪ Consistency
● Thyroid cartilage
● Cricoid cartilage
● Thyroid gland