PHYSICAL DIAGNOSIS

OUTLINE FOR HISTORY TAKING

I. GENERAL DATA: Name, Age, Birthdate, Birthplace, Sex, Civil Status, Occupation,
Nationality/Race, Religion, Present Address, number of times admitted in the hospital,
name of the hospital patient is admitted in, time and date of admission.

II. INFORMANT and % RELIABILITY:

- may be the patient, relative, friend, any accompanying person, a
letter of referral that can contribute largely on your patient’s medical
history (to assess the value and possible biases of the information)

- Reliability varies with knowledge, memory, trust, and motivation,

among other factors, and is a judgement made at the end of the
interview NOT at the beginning

-
III. CHIEF COMPLAINT/S: See Degowen
> one or more symptoms or other concerns for which the patient is seeking care
or advise
> Usually the answer to the question, “What symptom brought you to the
hospital?”
> Should be limited to a succinct word, phrase, or sentence, preferably as a
direct quote from the patient

IV. HISTORY OF PRESENT ILLNESS: See Degowen

> Determine as accurately as possible the date and manner of onset.
- develop the illness chronologically, analyze each symptom as it arises
> The patient’s previous treatment. Mention generic and brand names of the drugs
used. Include dosage, preparation, duration of use.

> Describe symptoms in terms of:

1) Provocative/Palliative (Factors that have aggravated or relieved them)
2) Quality
3) Radiation/Location (Where is it?)
4) Severity/Quantity (How bad is it?)
5) Timing (i.e., onset, duration, and frequency)
6) Setting in which they occur ( environmental factors, personal activities,
emotional reactions or other circumstances that may have contributed to the
illness)
7) Associated manifestations

> NOTE pertinent negatives ( the absence of certain symptoms that will aid in
differential diagnosis)
V. Past Medical History:
> previous hx of infectious disease – childhood and adult (list dates and
complications)
> immunization
> hx of operations, injuries, blood transfusions and operative diagnoses (list dates)
> previous hospitalization (list dates, diagnoses and names of hospital)
> Hx of previous and present disease NOT related to the present illness
> Allergies

VI. FAMILY HISTORY: See DeGowin and Bates

> includes chronic and degenerative disease, infections, neuro-psychiatric
disorders, and other heredo-familial diseases
> Parents, siblings, spouse or children - Age and health or age at death and cause

VII. PERSONAL & SOCIAL-ENVIRONMENTAL HX: see Bates and Degowen

- provision of information about the patient’s environment and what manner of
person the
patient is
- Personal:
> lifestyle issues that create risk or promote health, and health
maintenance issues ( e.g. smoking, food preference)
> Birthplace & Place of residence
> Marital History
> Gender preference
> Habits
> Religious affiliation and beliefs

- Social and economic status – standard of living, occupation, educational

attainment

- Environmental - description of place of residence and its

surrounding area;
- includes number of members in the household, drinking water
supply, toilet facilities, source of light (e.g. candles, electricity, gas)

VIII. REVIEW OF SYSTEMS: see DeGowin and Bates

> review of the history; inquiring for salient symptoms associated with each
system or anatomic region
> primarily, this is a search for symptoms that may have escaped during the
taking of the history of the present illness.
> place symptoms related to the present illness in the History of Present Illness;
anything unrelated to the HPI must be place in the Review of systems.