‫‪Taking a History‬‬

‫د‪ .‬امل عبد السالم الحداد‬

‫‪-‬قبل البدء بأخذ القصة المرضية قدم نفسك للمريض‬
‫واشرح للمريض ما ستقوم به واطلب االذن منه‪.‬‬
‫‪-‬اخذ القصة المرضية من المريض مهاره يجب‬
‫على جميع العامليين الصحيين ان يتقنوها‪.‬‬
‫‪-‬تذكر ان المريض بحاجة لك وانه ليس مجرد أداة‬
‫للتعلم‪.‬‬
‫‪-‬حاول كسب ثقة المريض وتقرب منه ((عامله كأنه‬
‫أحد اقاربك))‪.‬‬
‫‪-‬اكتب القصة المرضية بترتيب واسردها بطريقة‬
‫سهله للمستمع‪.‬‬
‫‪-‬استخدم أسئلة موضوعية وكن انت قائد المحادثة‬
‫مع المريض‪.‬‬

‫مع تمنياتي للجميع بالتوفيق‪.‬‬

 Internal
Medicine
History

:Personal History (hx)

Name, age, address (birthplace and
residence), occupation, marital status,
educational level, special habits of medical
:importance
Qat: period-frequency-length of each time -
(by hours)
smoking (cigarette, mada'a, shisha and -
shamma): period-type-frequency-amount-if
stopped ask why -passive smoking

Date of admission and through where (ER or

OPD)

ER= Emergency Room

.OPD= Out Patient Department

:Chief complain (C.C.)

The main reason of entering the hospital and
its duration (only one). ) by the patient own
.word's
In rare conditions, C.C. may be more than one
.but NEVER exceeds three
.do not use medical words here**

History of present illness

:(H.O.P.I.)
:Start to analyze any C.C. by six main things*
onset, 2-course, 3-duration, 4-increasing -1
factors, 5-decreasing factors and 6-associated
.factors
.Then analyze special things for every C.C**
After that ask about other signs and ***
.symptoms of the same system as the C.C

:Review of other systems

Ask about signs and symptoms of the other
.systems

Cardio.: palpitation, chest pain, dyspnea, -1

orthopnea, PND, syncope, claudication and
.ankle swelling

Respiratory: chest pain, dyspnea, cough, -2

.wheeze, sputum, hemostasis

G.I.T.: dysphagia, nausea, vomiting, -3

hematemesis, abdominal pain, diarrhea,
.constipation, melena, bleeding per rectum

Hepatobiliary system: jaundice, itching, -4

right hypochondrial pain, bleeding tendency,
.color of urine, color of stool
Renal system: flank pain, suprapubic pain, -5
dysuria, color and volume of urine, frequency
of micturition, hesitancy, urgency, drippling of
.urine, frothy urine

:.C.N.S-6
Mental: loss of consciousness, memory, and
.orientation….etc
.Motor: paresis or paralysis
.Sensory: hypo/hyperesthesia, anesthesia
Special sense: blurring of vision, tinnitus, loss
.of smell, loss of taste

Musculoskeletal: joint pain, swelling, -7

.stiffness, bone ache

Endocrine: heat or cold intolerance, change-8

.in weight or appetite
Hematological system: easy fatigability, -9
.bleeding tendency, jaudice

Generalized symptoms: fever, night -10

.sweating, loss of weight, loss of appetite

:Past history
:Past medical hx-1
similar condition in the past-
.any chronic disease: D.M., HTN, TB-
.previous hospital admissions-

:Past surgical hx-2

any previous surgeries-
accidents-
.blood transfusions (if yes ask why)-

:Past drug hx-3

.any drug used for a long time and why-

:Family hx
.parent consanguinity-
.similar condition in the family-
.chronic disease in the family-

:Socio-Economic hx
House: own/rented
Water source, electricity, sanitation, animal
.contact
Surgical
History
:Personal History (hx)
Name, age, address (birthplace and
residence), occupation, marital status,
educational level, special habits of medical
:importance
Qat: period-frequency-length of each time -
(by hours)
smoking (cigarette, mada'a, shisha and -
shamma): period-type-frequency-amount-if
.stopped ask why -passive smoking
Menstrual History (For female patient): age of
+.menarche and its regularity
+Ask about the use of contraceptive pills

Date of admission and through where (ER or

.OPD)
:Chief complain (C.C.)
The main reason of entering the hospital and
its duration (only one) by the patient own
.word's
In rare conditions, C.C. may be more than one
.but NEVER exceeds three
.do not use medical words here*
usually the C.C. here will be pain or **
.swelling
History of present illness
:(H.O.P.I.)
:Start to analyze any C.C. by six main things*
onset, 2-course, 3-duration, 4-increasing -1
factors, 5-decreasing factors and 6-associated
.factors
If the C.C. is pain add the following +
:questions
.Site-character-radiation-shifting of pain
If the C.C. is swelling add the following +
:questions
.Site-number-consistency-skin over it
.Then analyze special things for every C.C**
After that ask about other signs and ***
.symptoms of the same system as the C.C

:Review of other systems

Ask about signs and symptoms of the other
.systems

Cardio.: palpitation, chest pain, dyspnea, -1

orthopnea, PND, syncope, claudication and
.ankle swelling

Respiratory: chest pain, dyspnea, cough, -2

.wheeze, sputum, hemostasis

G.I.T.: dysphagia, nausea, vomiting, -3

hematemesis, abdominal pain, diarrhea,
.constipation, melena, bleeding per rectum

Hepatobiliary system: jaundice, itching, -4

right hypochondrial pain, bleeding tendency,
.color of urine, color of stool
Renal system: flank pain, suprapubic pain, -5
dysuria, color and volume of urine, frequency
of micturition, hesitancy, urgency, drippling of
.urine, frothy urine

:.C.N.S-6
Mental: loss of consciousness, memory, and
.orientation….etc
.Motor: paresis or paralysis
.Sensory: hypo/hyperesthesia, anesthesia
Special sense: blurring of vision, tinnitus, loss
.of smell, loss of taste

Musculoskeletal: joint pain, swelling, -7

.stiffness, bone ache

Endocrine: heat or cold intolerance, change-8

.in weight or appetite
Hematological system: easy fatigability, -9
.bleeding tendency, jaudice

Generalized symptoms: fever, night -10

.sweating, loss of weight, loss of appetite

:Past history
:Past medical hx-1
similar condition in the past-
.any chronic disease: D.M., HTN, TB-
.previous hospital admissions-

:Past surgical hx-2

any previous surgeries-
accidents-
.blood transfusions (if yes ask why)-

:Past drug hx-3

.any drug used for a long time and why-

:Family hx
.parent consanguinity-
.similar condition in the family-
.chronic disease in the family-

:Socio-Economic hx
House: own/rented
Water source, electricity, sanitation, animal
.contact
Pediatric
History
:Personal History (hx)
Name, age, address (birthplace and
residence), source of information and date of
.admission

:Chief complain (C.C.)

The main reason of entering the hospital and
its duration (only one) by the patient or
.relative own word's
In rare conditions, C.C. may be more than one
.but NEVER exceeds three
.do not use medical words here**
History of present illness
:(H.O.P.I.)
:Start to analyze any C.C. by six main things*
onset, 2-course, 3-duration, 4-increasing -1
factors, 5-decreasing factors and 6-associated
.factors
.Then analyze special things for every C.C**
After that ask about other signs and ***
.symptoms of the same system as the C.C
:Review of other systems

Ask about signs and symptoms of the other

.systems

Cardio.: palpitation, chest pain, dyspnea, -1

orthopnea, PND, syncope, claudication and
.ankle swelling

Respiratory: chest pain, dyspnea, cough, -2

.wheeze, sputum, and hemopstasis

G.I.T.: dysphagia, nausea, vomiting, -3

hematemesis, abdominal pain, diarrhea,
.constipation, melena, bleeding per rectum
Hepatobiliary system: jaundice, itching, -4
right hypochondrial pain, bleeding tendency,
.color of urine, color of stool

Renal system: flank pain, suprapubic pain, -5

dysuria, color and volume of urine, frequency
of micturition, hesitancy, urgency, drippling of
.urine, frothy urine

:.C.N.S-6
Mental: loss of consciousness, memory, and
.orientation….etc
.Motor: paresis or paralysis
.Sensory: hypo/hyperesthesia, anesthesia
Special sense: blurring of vision, tinnitus, loss
.of smell, loss of taste

Musculoskeletal: joint pain, swelling, -7

.stiffness, bone ache
Endocrine: heat or cold intolerance, change-8
.in weight or appetite
Hematological system: easy fatigability, -9
.bleeding tendency, jaudice

Generalized symptoms: fever, night -10

.sweating, loss of weight, loss of appetite
:Developmental History+
)You have to know the normal development(
Ask about the motor, social and speech -
.milestones

:Vaccination History+
You have to know every vaccine and when to(
)give it
Ask if vaccine was taken or not, if yes ask -
?what is it and did it cause any complication

Dietic History (Nutritional +

:History)
.Ask about breast-feeding-
.Ask about artificial milk in details-
.Ask about complementary food in detail-
:Pre-Natal History+
.Drugs used during pregnancy-
.Diseases during pregnancy-
.Radiation During pregnancy-

:Natal History+
place of birth, type of delivery, was there any-
.complication or not

:Post-Natal History+
Did the baby cry immediately or not? Was -
?there any cyanosis, jaundice or bleeding
:Past history

:Past medical hx-1

similar condition in the past-
.any chronic disease: D.M., HTN, TB-
.previous hospital admissions-

:Past surgical hx-2

any previous surgeries-
accidents-
.blood transfusions (if yes ask why)-

:Past drug hx-3

.any drug used for a long time and why-
:Family hx
.parent consanguinity-
.similar condition in the family-
.chronic disease in the family-

:Socio-Economic hx
House: own/rented
Water source, electricity, sanitation, animal
.contact
Examples of
a History
:Example 1

Osama ali mohammed saleh a 30 year old

male patient from Sanaa and living there,
married and has 4 children he is a teacher, he
chews qat for 2 hours for the last 4 years and
smokes 12 cigarettes per day for the last 10
years
He was admitted at 24th of July 2018 through
OPD

:.C.C
Cough, 2 weeks prior to admission

:.H.O.P.I
My patient was well until 2 weeks ago where
he started to complain of cough that was
gradual in onset progressive in course for 2
weeks. Increased at night decreased slightly
by medications and associated with fever that
increased at night and was associated with
.chills
This cough was dry then stared to be frothy
and bloody. He also complained of loss of
.weight and appetite
There was no chest pain, wheezing or
.dyspnea

:Review of other systems

Cardio.: no palpitation, chest pain, dyspnea, -

orthopnea, PND, syncope, claudication or
.ankle swelling

G.I.T.: NO dysphagia, nausea, vomiting, -

hematemesis, abdominal pain, diarrhea,
.constipation, melena or bleeding per rectum
Hepatobiliary system: NO jaundice, itching, -
right hypochondrial pain, bleeding tendency,
.no change in color of urine and color of stool

Renal system: NO flank pain, suprapubic -

pain, dysuria, color and volume of urine,
frequency of micturition, hesitancy, urgency,
.drippling of urine or frothy urine

:.C.N.S-
Mental: NO loss of consciousness, normal
.memory, and orientation
.Motor: NO paresis or paralysis
.Sensory: NO hypo/hyperesthesia, anesthesia
Special sense: NO blurring of vision, tinnitus,
.loss of smell and loss of taste

Musculoskeletal: NO joint pain, swelling, -

.stiffness, bone ache
Endocrine: NO heat or cold intolerance, -
.change in weight or appetite
Hematological system: easy fatigability, -9
.bleeding tendency, jaudice

Generalized symptoms: there is fever, night -

sweating, there loss of weight and there is
.loss of appetite

:Past history

:Past medical hx-1

There was no similar condition in the past-
.No any chronic disease: D.M., HTN, TB-
.NO previous hospital admissions-
:Past surgical hx-2
No any previous surgeries-
No accidents-
.No blood transfusions-

:Past drug hx-3

.No any drug used-

:Family hx
.No parent consanguinity -
There was similar condition with his father in-
.the last month
.NO chronic disease in the family-
:Socio-Economic hx
He lives in their own house with poor water
source and sanitation and there is no animal
.contact
They are of mid socioeconomic class

.
)))) ?Did You Know The Diagnosis ((((
:Example 2

Male patient named Abdulrahman

mohammed mohammed ali he is a 17 year
old student from Taiz and living in Sanaa he is
single and doesn’t have any special habits of
.medical importance
Was admitted at first of august 2018 through
.ER
:.C.C
.Abdominal pain 2 days prior to admission
.H.O.P.I:
He was well until 48 hours ago where he
started to complain of abdominal pain that
was sudden in onset progressive in course for
2 days pain stared around the umbilicus then
was shifted to the right iliac fossa and it was
dull aching in character, was increased by
movement and not relieved by anything
patient also complained of nausea and
vomiting and anorexia but there was no
.diarrhea, constipation or hematemesis

:Review of other systems

Cardio.: no palpitation, chest pain, dyspnea, -

orthopnea, PND, syncope, claudication or
.ankle swelling

Respiratory: no chest pain, dyspnea, cough, -

.wheeze, sputum, hemostasis
Hepatobiliary system: NO jaundice, itching, -
right hypochondrial pain, bleeding tendency,
.no change in color of urine and color of stool

Renal system: NO flank pain, suprapubic -

pain, dysuria, color and volume of urine,
frequency of micturition, hesitancy, urgency,
.drippling of urine or frothy urine

:.C.N.S-
Mental: NO loss of consciousness, normal
.memory, and orientation
.Motor: NO paresis or paralysis
.Sensory: NO hypo/hyperesthesia, anesthesia
Special sense: NO blurring of vision, tinnitus,
.loss of smell and loss of taste
Musculoskeletal: NO joint pain, swelling, -
.stiffness, bone ache

Endocrine: NO heat or cold intolerance, -

.There was change in weight and appetite
Hematological system: NO easy fatigability, -
.bleeding tendency, or jaundice

Generalized symptoms: there is no fever, -

night sweating, there loss of weight and there
.is loss of appetite

:Past history

:Past medical hx-1

There was no similar condition in the past-
.No any chronic disease: D.M., HTN, TB-
.NO previous hospital admissions-
:Past surgical hx-2
No any previous surgeries-
No accidents-
.No blood transfusions-

:Past drug hx-3

.No any drug used-

:Family hx
.No parent consanguinity -
.There was no similar condition-
.NO chronic disease in the family-
:Socio-Economic hx
He lives in a rented house with poor water
source and sanitation and there is no animal
.contact
.They are of low socioeconomic class

)))) ?Did You Know The Diagnosis ((((

:Example 3

This history was taken at 8/8/2018

Mariam hussain ahmed salah a 1 year and 10
month old female patient from yareem and
.lives there
.She is the first child out of two
She was admitted today by referral from a
.privet hospital

:.C.C
Body swelling 2 days prior to admission

:.H.O.P.I
Patient was quite well until her mother
noticed that she has swelling all over the
body, it started at the dorsa of feet and hands
then progressed to be at the face arms and
thighs and abdomen, edema is bilateral
pitting and painless. The mother also
.complained of hair fall and scaling of the skin

:Review of other systems

Cardio.: no palpitation, chest pain, dyspnea, -

orthopnea, PND, syncope, claudication or
.ankle swelling

Respiratory: no chest pain, dyspnea, cough, -

.wheeze, sputum, hemostasis

G.I.T.: there is, diarrhea, abdominal -

distention and anorexia but no dysphagia
nausea, vomiting, hematemesis, abdominal
pain, constipation, melena or bleeding per
.rectum
Hepatobiliary system: NO jaundice, itching, -
right hypochondrial pain, bleeding tendency,
.no change in color of urine and color of stool

Renal system: NO flank pain, suprapubic -

pain, dysuria, color and volume of urine,
frequency of micturition, hesitancy, urgency,
.drippling of urine or frothy urine

:.C.N.S-
Mental: NO loss of consciousness, normal
.memory, and orientation
.Motor: NO paresis or paralysis
.Sensory: NO hypo/hyperesthesia, anesthesia
Special sense: NO blurring of vision, tinnitus,
.loss of smell and loss of taste
Musculoskeletal: NO joint pain, swelling, -
.stiffness, bone ache

Endocrine: NO heat or cold intolerance, -

.There was change in weight and appetite
Hematological system: NO easy fatigability, -
.bleeding tendency, or jaundice

Generalized symptoms: there is no fever, -

night sweating, there loss of weight and there
.is loss of appetite

:Developmental History
Normal developmental milestone till now
.patient can ascend stairs in child manner
The mother complains that the child is always
.depressed and social adaptation is bad
.The child says 3 words
:Vaccination History
Vaccine is up to date

:Dietic History
Was on exclusive breast feeding till 6 months
then weaned by food in form of ( shabeesa )
and artificial milk ( 250 cc water and one
spoon of powder milk ) then at 1 year baby
.was given starchy (carbohydrate diet)

:Pre-Natal History
Mother didn’t have any disease and did not
take any drugs or had any radiation test

:Natal History
Full term delivery at home without any
.maternal or fetal complications
:Post-Natal History
Baby cried immediately no cyanosis jaundice
.or bleeding

:Past history

:Past medical hx-1

There was no similar condition in the past-
..No any chronic disease-
.NO previous hospital admissions-

:Past surgical hx-2

No any previous surgeries-
No accidents-
.No blood transfusions-
:Past drug hx-3
.No any drug used-

:Family hx
Parent are related (there is parent -
consanguinity)
.There was no similar condition-
.NO chronic disease in the family-

:Socio-Economic hx
they lives in a rented house with poor water
source and sanitation and there is animal
contact
.They are of low socioeconomic class

)))) ?Did You Know The Diagnosis ((((