HISTORY

This is a 45 year-old male, presented to the ER with a history of chest pain, 2 hours ago, take a relevant history. Profile Chief complaint and duration (chest pain, remained for how long?) HPI (analysis for chief complaint SOCRATES, A: Cardiac symptoms (SOB/orthopnea/PNDs, pain, edema, palpitations, intermittent claudication, and syncope). General symptoms (headache, sweating, nausea). Other suspected systems (cough, wheezes). Relation to position and respiration. Conditions before pain (food, exercise, cold) what was he doing? First attack or not? Activity, exercise tolerance) Past history (HTN, DM, ACS, catheterizations, ask if HTN and DM are controlled or not) Drugs and allergies (what drugs has he taken, allergies to foods or drugs) Family history (of HTN, DM, controlled, ACS) Social history (smoking and alcohol)

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This is a 33 year-old male, presented with hemoptysis, take a relevant history, then give your diagnosis. Profile (mentioned) Chief complaint and duration (duration: 3 months) HPI (analysis of chief complaint: smoking (how many packs/day, for how many years) onset, timing, exacerbating/relieving factors, associated symptoms (cough (day/night variation, timing, relation to food and to hemoptysis), sputum (amount and color), shortness of breath, fever (day/night variation, documented), weight loss, appetite, night sweats, masses, contact to sick people. Bleeding from other sites. First attack or not) Past history (past illnesses) Drugs and allergies Family history of same condition Social history (where does he live, contact to animals)

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21 year-old female, presented with epigastric pain for the last 6 months, take a relevant history. Profile (mentioned) Chief complaint and duration (mentioned) HPI (analysis of pain SOCRATES, A: nausea, vomiting, heartburn, sweating, diarrhea/constipation and normal bowel habit, melena, pain awakens from sleep, Page 1

JMSA training

complaining of lower limb swelling for the last month. DM. appetite. regurgitation. Other causes of effusion: low protein. above knee). edema in abdomen or lower limbs. cough and sputum analysis. Profile (mentioned) Chief complaint and duration (mentioned) HPI (analysis of chief complaint: appetite. pain (pleuritic/central. weight loss. activity. early satiety. exercise. loss of appetite and weight. to menses. to stress) Past history Drugs and allergies Social history (smoking and alcohol) 24 year-old female. activity. complaining of shortness of breath for the last 2 weeks. type of food and drinks. shortness of Page 2 JMSA training . fever. ACS. exercise. vomiting and nausea. onset (sudden vs progressive) timing (on and off). tremor. timing. oligomenorrhea. orthopnea/PNDs. painful/painless. Relation to food and drinks (time and type). palpitations. intermittent claudication. Profile Chief complaint and duration HPI (analysis: unilateral/bilateral. number of meals. claiming that she lost 6 kgs (from 62 to 56) though she’s not on diet. fever. pregnancy) Drugs and allergies Family history (of thyroid disease) Social history (smoking) - 67 year-old male.- dysphagia. position). masses. anemia (fatigability). work. smoking) Past history (HTN. nervousness. sweats/night sweats. take a relevant history. take relevant history. borders (below knee. exercise. relation to breathing. diarrhea/constipation. abdominal/epigastric pains. neck masses. exercise. asthma and COPD) Drugs and allergies Family Social - 30 year-old male. take a relevant history. lifestyle. heat intolerance. Profile Chief complaint and duration HPI (analysis: onset (sudden vs slow). fatigability. activity. distension. happy about her weight) Past history (radiation.

activity. abdominal pain analysis. chest pain. low protein: proteinuria. ask about control -> eyes. etc) Drugs and allergies (he’s on insulin and antihypertensive) Family Social (smoking. contact with animals) - - 20 year-old female. complaining of diarrhea for the last 3 months. appetite. complaining of bloating for the last 5 years. DM -> the patient has DM type I and HTN. smell and appearance of urine) Past history (HTN. Profile Chief complaint and duration HPI (analysis: onset. hands and feet. ask about previous admissions because of same problem. color.4. smoking. Flatulance. chest pain and relation to breathing and sleeping. Past history (DM. type of foods. Profile Chief complaint and duration HPI (analysis: onset. day/night variation awakes him from sleep. incontinence. timing. flushing. stands most of the time) 60 year-old patient complaining of chronic cough for the last 3 years. diarrhea/constipation analysis. hesitancy. number of meals. exercise tolerance. Take a relevant history. HTN. sleeping. details about food intake. progression. other urinary symptoms: frequency. menses) Past history Drugs and allergies Family history (of same condition) Social - 32 year-old male. conjunctivitis. fatigue. fever. asthma or COPD (he doesn’t know if he has asthma or COPD). bleeding. her Hb was 7. sputum amount and color. amount. eczema)) Family history (asthma or atopy) Social (smoking. progression. color. dizziness. Profile Page 3 JMSA training . timing. shortness of breath. fever. take a relevant history. relation to food and drinks. weight gain. occupation -> he’s a teacher. MCV 65. appetite. nausea and vomiting. Then ask about symptoms of anemia: SOB. weight loss. urgency.- breath. Take a relevant history. hemoptysis. personal history of asthma or atopy (allergic rhinitis. hemoptysis.

joint pains. consistency. ask about eye symptoms and diarrhea. then symptoms of most suspected system. analysis of pain.Always start with analyzing chief complaint. skin manifestations or discolorations.com . feeling of mass during defecation. or amount of stool (normal bowel habit: three times/day to once/three days) . detailed analysis of defecation: tinismus. nausea. consistency and amount. awakens from sleep.Joint pain (Rheumatoid arthritis. .History of melena (Peptic ulcer) . look criteria for RA) .Analyze each symptom and its relation to the chief complain (if the patient chiefly complaining of pain and has vomiting. frequency.- - Chief complaint and duration HPI (analysis: deviation of normal bowel habit regarding frequency. blurred vision. consistency. appetite. urgency to defecate. distention. color) and its relation to pain (did it happen before pain or after? Did it relieve you pain?) JMSA training Page 4 www. easily flushed or not. Extraintestinal manifestations: eye pain. pain relieved by defecation or not.When there’s a joint pain. . vomiting. palpable masses) Past history (previous admissions) Drugs and allergies Family history (of same condition) Social (smoking and alcohol) Other questions: . then general symptoms.Diarrhea and constipation refers to change in frequency. abdominal pain. weight.sawa2006. presence of mucus or blood or melena. analyze vomiting (amount. color of stool.Fever of unknown origin (brucellosis) Notes: . And when there’s diarrhea ask about joint pain and eye symptoms.

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