Section 1 General History/PE

Begin
Knock on the door (wait 2 sec.)
Hello Mr/Ms. XYZ, nice to meet you, (shake hands). I am doctor Veluponnar, the duty doctor today,
and I am here to ask you a few questions.
Let me make you more comfortable (drape the patint)
So, what cause you to come in today? I am sorry to hear that
Can you tell me more about your problem?

HPI: LQQ OPERA, ask PDF alone with O, or LIQURAAA

Location: Wheres the location of the pain?
Quality: Can you describe your pain? for example, sharp/dull/burning/or pressure like?
Quantity: On a scale of 1-10, with 10 being the worst, how would you rate your pain?
Onset: When did it start? How did it start? What were you doing when it started? (Past:
Did you experience the same problem before?)
Duration: How long does it last?
Frequency (timing): How often does it occur?
Is the pain constant or intermittent?
Is it getting better or worse? What time in a day does it usually present?
Precipitation: Do you remember anything that might have caused it? Is ther any relationship with food
and pain (in epigastric pain case)? Any relationship between the position and the dizziness?
Exacerbation: Do you know anything that can make the pain worse?
Relieving (radiation): Do you know anything that can make the pain better? Does the pain move to
somewhere else? Have you tried anything to help?
Associated symptoms: Do you have other symptoms right now? Is that all the symptoms you have?

PHM: PAM HUGS FOS EAST SODA

Begin with transition sentence:
I need to ask you a few questions about your health in the past, is that okay?
I need to ask you a few questions about your family health, is that okay?
Can I ask you about your sexual and personal life, itll we confidential if no answer: I would like to
know the whole picture of your health condition and your information can be very helpful, (pause), is
that Ok?

Past medical history: Do you have any illness in the past? Any operation? Any trauma? (Dizziness,
pain cases, headache), Easy bleeding (in any bleeding case), DM/HTN/Hyperlipidemia (in limbs
weakness/numbness, erectile dysfunction)
Allergy: Are you allergic to anything
Medical: Medication: Are you currently taking any medication including over-the-counter medication
and prescribed medication? Side effect?
Procedure: Any blood transfusion (in anemia cases), when is you last PPD? (if suspected TB),
Has your colon been examined with any device? (colonscope in jaundice/blood in stool case)
Hospitalization: Have you been admitted to hospital before?
Urinary; Do you have any urinary symptoms? Do you have trouble urinating?
Is there any change to your urine habit? Is there any change to urine color?
GI: Do you have any bowel symptoms for example loose bowel? Is there any change to your bowel
habit? Is there any change to stool color?

Family: Is there any illness in your family?

Ob/Gyn: When was your last menstrual period? (ask in detail if needed)

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