What is History taking ?

It is a process by which information is gained by a physician by asking

specific questions to the patient with the aim of obtaining information
useful in formulating a diagnosis and providing medical care to the patient
‫إﻧﮭﺎ ﻋﻣﻠﯾﺔ ﯾﺗم ﻣن ﺧﻼﻟﮭﺎ اﻟﺣﺻول ﻋﻠﻰ اﻟﻣﻌﻠوﻣﺎت ﻣن ﻗﺑل اﻟطﺑﯾب ﻣن ﺧﻼل طرح أﺳﺋﻠﺔ ﻣﺣددة ﻋﻠﻰ‬
‫اﻟﻣرﯾض ﺑﮭدف اﻟﺣﺻول ﻋﻠﻰ ﻣﻌﻠوﻣﺎت ﻣﻔﯾدة ﻓﻲ ﺻﯾﺎﻏﺔ اﻟﺗﺷﺧﯾص وﺗﻘدﯾم اﻟرﻋﺎﯾﺔ اﻟطﺑﯾﺔ ﻟﻠﻣرﯾض‬
Importance of History Taking?
Obtaining an accurate history is the critical first step in determining the
etiology of a patient's illness.
‫ﯾﻌد اﻟﺣﺻول ﻋﻠﻰ ﺗﺎرﯾﺦ دﻗﯾﻖ ھو اﻟﺧطوة اﻷوﻟﻰ اﻟﺣﺎﺳﻣﺔ ﻓﻲ ﺗﺣدﯾد ﻣﺳﺑﺑﺎت ﻣرض اﻟﻣرﯾض‬
- Diagnosis in medicine is based on Clinical history
‫ﯾﻌﺗﻣد اﻟﺗﺷﺧﯾص ﻓﻲ اﻟطب ﻋﻠﻰ اﻟﺗﺎرﯾﺦ اﻟﺳرﯾري‬
- Physical Examination ‫اﻟﻔﺣص اﻟﺑدﻧﻲ‬
- Investigations ‫اﻟﺗﺣﻘﯾﻘﺎت‬
A large percentage of the time (70%), you will actually be able make a
diagnosis based on the history alone.
‫ﻗﺎدرا ﻓﻲ اﻟواﻗﻊ ﻋﻠﻰ إﺟراء ﺗﺷﺧﯾص ﺑﻧﺎ ًء ﻋﻠﻰ اﻟﺗﺎرﯾﺦ وﺣده‬
ً ‫ ﺳﺗﻛون‬، )٪70( ‫ﻧﺳﺑﺔ ﻛﺑﯾرة ﻣن اﻟوﻗت‬
How to take a history ?
The basis of a true history is good communication between doctor and
patient. It takes practice, patience, understanding and concentration.
‫ ﯾﺗطﻠب اﻷﻣر اﻟﻣﻣﺎرﺳﺔ واﻟﺻﺑر واﻟﺗﻔﺎھم واﻟﺗرﻛﯾز‬.‫أﺳﺎس اﻟﺗﺎرﯾﺦ اﻟﺣﻘﯾﻘﻲ ھو اﻟﺗواﺻل اﻟﺟﯾد ﺑﯾن اﻟطﺑﯾب واﻟﻣرﯾض‬
"Always listen to the patient they
Approach to history taking might be telling you the diagnosis.
(sir willam Osler 1849 - 1919)
Your look is important ‫ﻣظﮭرك ﻣﮭم‬
‫اﺳﺗﻣﻊ داﺋ ًﻣﺎ إﻟﻰ اﻟﻣرﯾض‬
Your dressing ‫ﻣﻼﺑﺳك‬ ‫ﻷﻧﮭم ﻗد ﯾﺧﺑروك ﺑﺎﻟﺗﺷﺧﯾص‬
Approach to history taking
Introduce yourself and create a rapport ‫ﻗدم ﻧﻔﺳك وأﺧﻠﻖ ﻋﻼﻗﺔ‬

Approach to history taking

Be alert and pay full attention ‫ظﺎ وﻣﻧﺗﺑﺔ ﺗﻣﺎ ًﻣﺎ‬
ً ‫ﻛن ﻣﺗﯾﻘ‬
 Approach to history taking
- Ensure consent has been gained. ‫ﺗﺄﻛد ﻣن اﻟﺣﺻول ﻋﻠﻰ اﻟﻣواﻓﻘﺔ‬
- Maintain privacy and dignity. ‫اﻟﺣﻔﺎظ ﻋﻠﻰ اﻟﺧﺻوﺻﯾﺔ واﻟﻛراﻣﺔ‬
- Ensure the patient is as comfortable as possible. ‫ﺗﺄﻛد ﻣن أن اﻟﻣرﯾض ﻣرﺗﺎح ﻗدر اﻹﻣﻛﺎن‬
- Summarise each stage of the history taking process.
‫ﻟﺧص ﻛل ﻣرﺣﻠﺔ ﻣن ﻣراﺣل ﻋﻣﻠﯾﺔ أﺧذ اﻟﺗﺎرﯾﺦ‬
- Involve the patient in the history taking process. ‫إﺷراك اﻟﻣرﯾض ﻓﻲ ﻋﻣﻠﯾﺔ أﺧذ اﻟﺗﺎرﯾﺦ‬
If in a bad mood or distracted during the consultation, you can end up
making a history rather than taking a history.
‫ ﻓﻘد ﯾﻧﺗﮭﻲ ﺑك اﻷﻣر ﺑﺻﻧﻊ ﺗﺎرﯾﺦ ﺑدﻻً ﻣن أﺧذ اﻟﺗﺎرﯾﺦ‬، ‫إذا ﻛﻧت ﻓﻲ ﺣﺎﻟﺔ ﻣزاﺟﯾﺔ ﺳﯾﺋﺔ أو ﻣﺷﺗﺗًﺎ أﺛﻧﺎء اﻻﺳﺗﺷﺎرة‬
Components of History taking
1- Patient's profile ‫ اﻟﻣﻠف اﻟﺷﺧﺻﻲ ﻟﻠﻣرﯾض‬-١
2- Chief complaint ‫ ﺷﻛوى رﺋﯾﺳﯾﺔ‬-٢
3- History of the present illness ‫ ﺗﺎرﯾﺦ اﻟﻣرض اﻟﺣﺎﻟﻲ‬-٣
4- Past medical history ‫ اﻟﺗﺎرﯾﺦ اﻟطﺑﻲ اﻟﺳﺎﺑﻖ‬-٤
5- Family history ‫ ﺗﺎرﯾﺦ اﻟﻌﺎﺋﻠﺔ‬-٥
6- Socioeconomic history ‫ اﻟﺗﺎرﯾﺦ اﻻﺟﺗﻣﺎﻋﻲ واﻻﻗﺗﺻﺎدي‬-٦
7- System Review ‫ ﻣراﺟﻌﺔ اﻟﻧظﺎم‬-٧
1. Patients profile
‫ اﻟﻌﻣر‬, ‫ اﻻﺳم‬, ‫اﻟﺗﺎرﯾﺦ واﻟوﻗت‬
- Date and Time - Name - Age ‫ اﻟﺣﺎﻟﺔ اﻻﺟﺗﻣﺎﻋﯾﺔ‬, ‫ اﻟدﯾن‬, ‫اﻟﺟﻧس‬
- Sex - Religion - Marital status ‫ ﻣن أﻋطﻰ اﻟﺗﺎرﯾﺦ؟‬, ‫ اﻟﻌﻧوان‬, ‫اﻟﻣﮭﻧﺔ‬
- Occupation - Address - Who gave the history?
2. Chief complaint
- The main reason for which the patient is trying to seek medical help by
visiting the physician.
‫اﻟﺳﺑب اﻟرﺋﯾﺳﻲ اﻟذي ﻣن أﺟﻠﮫ ﯾﺣﺎول اﻟﻣرﯾض طﻠب اﻟﻣﺳﺎﻋدة اﻟطﺑﯾﺔ ﻣن ﺧﻼل زﯾﺎرة اﻟطﺑﯾب‬
- Usually a single symptoms, occasionally more than one complaints eg:
fever, headache, pain, etc
‫ إﻟﺦ‬، ‫ واﻷﻟم‬، ‫ واﻟﺻداع‬، ‫ اﻟﺣﻣﻰ‬:‫ وأﺣﯾﺎﻧﺎ ً أﻛﺛر ﻣن ﺷﻛوى ﻣﺛل‬، ‫ﻋﺎدة أﻋراض واﺣدة‬
- The patient describe the problem in their own words.
‫ﯾﺻف اﻟﻣرﯾض اﻟﻣﺷﻛﻠﺔ ﺑﻛﻠﻣﺎﺗﮫ اﻟﺧﺎﺻﺔ‬
- It should be recorded in patients own words.
‫ﯾﺟب ﺗﺳﺟﯾﻠﮫ ﺑﻛﻠﻣﺎت اﻟﻣرﺿﻰ اﻟﺧﺎﺻﺔ‬
- The complain should be recorded with their onset duration.
‫ﯾﺟب ﺗﺳﺟﯾل اﻟﺷﻛوى ﻣﻊ ﻣدﺗﮭﺎ اﻷوﻟﻰ‬
2. Chief complaint
- How to ask for chief complaint? ‫ﻛﯾف ﺗﺳﺄل ﻋن ﺷﻛوى رﺋﯾﺳﯾﺔ؟‬
- What brings your here? ‫ﻣﺎ اﻟذي أﺗﻰ ﺑك ھﻧﺎ؟‬
- How can I help you? ‫ﻛﯾف ﯾﻣﻛﻧﻧﻲ ﻣﺳﺎﻋدك؟‬
- What seems to be the problem? ‫ﻣﺎ اﻟذى ﯾﺑدو اﻧﮫ ﻣﺷﻛﻠﮫ؟‬
If there is more than one complaint, it should be written according to
chronological order ‫ ﯾﺟب ﻛﺗﺎﺑﺗﮭﺎ ﺣﺳب اﻟﺗرﺗﯾب اﻟزﻣﻧﻲ‬، ‫ﻓﻲ ﺣﺎﻟﺔ وﺟود أﻛﺛر ﻣن ﺷﻛوى‬
2. Chief complaint Example
Fever-2 weeks ‫ أﺳﺑوﻋﯾن‬- ‫ﺣﻣﻰ‬
Productive cough-1 week ‫ أﺳﺑوع‬1 - ‫اﻟﺳﻌﺎل اﻟﻣﻧﺗﺞ‬
Vomiting -2 days ‫ ﯾوﻣﯾن‬- ‫اﻟﻘﻲء‬
Fatigue-1day ‫ ﯾوم‬1- ‫اﻟﺗﻌب‬
 3. History of the present illness
- Elaborate on the chief complaint in detail Ask relevant associated
symptoms Gain as much information you can about the specific complaint.
‫وﺿﺢ اﻟﺷﻛوى اﻟرﺋﯾﺳﯾﺔ ﺑﺎﻟﺗﻔﺻﯾل اﺳﺄل اﻷﻋراض ذات اﻟﺻﻠﺔ ذات اﻟﺻﻠﺔ اﺣﺻل ﻋﻠﻰ أﻛﺑر ﻗدر ﻣﻣﻛن ﻣن‬
‫اﻟﻣﻌﻠوﻣﺎت ﺣول اﻟﺷﻛوى اﻟﻣﺣددة‬
- Lead the conversation by asking questions. ‫ﻗم ﺑﻘﯾﺎدة اﻟﻣﺣﺎدﺛﺔ ﺑطرح اﻷﺳﺋﻠﺔ‬
- Always start with an open ended question and take the time to listen to the
patient's 'story. ‫اﺑدأ داﺋ ًﻣﺎ ﺑﺳؤال ﻣﻔﺗوح وﺧذ اﻟوﻗت اﻟﻛﺎﻓﻲ ﻟﻼﺳﺗﻣﺎع إﻟﻰ ﻗﺻﺔ اﻟﻣرﯾض‬
- Once the patient has completed their narrative then closed questions can
be asked to clarify. ‫ ﯾﻣﻛن طرح أﺳﺋﻠﺔ ﻣﻐﻠﻘﺔ ﻟﻠﺗوﺿﯾﺢ‬، ‫ﺑﻣﺟرد أن ﯾﻛﻣل اﻟﻣرﯾض ﺳرده‬
- Leading question are to be avoided. ‫ﯾﺟب ﺗﺟﻧب اﻟﺳؤال اﻟرﺋﯾﺳﻲ‬
- Open questions allow patients to express their own thoughts and feelings,
e.g. 'Is there anything else that you want to mention?
‫ ﻋﻠﻰ ﺳﺑﯾل اﻟﻣﺛﺎل ھل ھﻧﺎك أي ﺷﻲء آﺧر ﺗرﯾد ذﻛره؟‬، ‫اﻷﺳﺋﻠﺔ اﻟﻣﻔﺗوﺣﺔ ﺗﺳﻣﺢ ﻟﻠﻣرﺿﻰ ﺑﺎﻟﺗﻌﺑﯾرﻋن أﻓﻛﺎرھم وﻣﺷﺎﻋرھم‬
- Closed questions are requests for factual information, e.g. When did this
pain start?. ‫ ﻋﻠﻰ ﺳﺑﯾل اﻟﻣﺛﺎل ﻣﺗﻰ ﺑدأ ھذا اﻷﻟم؟‬، ‫اﻷﺳﺋﻠﺔ اﻟﻣﻐﻠﻘﺔ ھﻲ طﻠﺑﺎت ﻟﻠﺣﺻول ﻋﻠﻰ ﻣﻌﻠوﻣﺎت واﻗﻌﯾﺔ‬
- Leading questions are based on your own assumptions that lead the
patient to the answer you want to hear.
‫ﺗﺳﺗﻧد اﻷﺳﺋﻠﺔ اﻟراﺋدة ﻋﻠﻰ اﻓﺗراﺿﺎﺗك اﻟﺧﺎﺻﺔ اﻟﺗﻲ ﺗﻘود اﻟﻣرﯾض إﻟﻰ اﻹﺟﺎﺑﺔ اﻟﺗﻲ ﺗرﯾد ﺳﻣﺎﻋﮭﺎ‬
3. History of the present illness
- In details of present problem with- time of onset/ mode of evolution/ any
investigation;treatment &outcome/any associated +'ve or -'ve symptoms.
‫ أي أﻋراض‬/ ‫ أي ﺗﺣﻘﯾﻖ ؛ اﻟﻌﻼج واﻟﻧﺗﯾﺟﺔ‬/ ‫ ﻧﻣط اﻟﺗطور‬/ ‫ وﻗت اﻟﺑداﯾﺔ‬- ‫ﻓﻲ ﺗﻔﺎﺻﯾل اﻟﻣﺷﻛﻠﺔ اﻟﺣﺎﻟﯾﺔ‬
‫ ﺧﻣﺳﺔ أو ﻗد ظﮭرت‬+ ‫ﻣرﺗﺑطﺔ‬
- Avoid medical terminology and make use of a descriptive language that is
familiar to patients. ‫ﺗﺟﻧب اﻟﻣﺻطﻠﺣﺎت اﻟطﺑﯾﺔ واﺳﺗﻔد ﻣن ﻟﻐﺔ وﺻﻔﯾﺔ ﻣﺄﻟوﻓﺔ ﻟﻠﻣرﺿﻰ‬
- Sequential presentation. ‫ﻋرض ﻣﺗﺳﻠﺳل‬
- Always relay story in days before admission.
‫اﺣرص داﺋ ًﻣﺎ ﻋﻠﻰ ﻧﻘل اﻟﻘﺻﺔ ﻓﻲ اﻷﯾﺎم اﻟﺗﻲ ﺗﺳﺑﻖ اﻟﻘﺑول‬
- Narrate in details. ‫روا ﺑﺎﻟﺗﻔﺻﯾل‬
 3. History of the present illness
Tips to gather information:
•S Site •O Onset •C Character ‫ﻣوﻗﻊ • ﺑداﯾﺔ • ﺣرف‬
•R Radiation (of pain or discomfort) ‫إﺷﻌﺎع (ﻟﻸﻟم أو ﻋدم اﻟراﺣﺔ‬
•A Alleviating factors •T Timing ‫اﻟﻌواﻣل اﻟﻣﺧﻔﻔﺔ • اﻟﺗوﻗﯾت‬
•E Exacerbating factors •S Severity ‫ﻋواﻣل ﻣﻔﺎﻗﻣﺔ • ﺷدة‬
4. Past medical history
- Any history of similar complaint in the past ‫أي ﺗﺎرﯾﺦ ﻣن ﺷﻛوى ﻣﻣﺎﺛﻠﺔ ﻓﻲ اﻟﻣﺎﺿﻲ‬
- Other medical problems the patient has or had
‫ﻣﺷﺎﻛل طﺑﯾﺔ أﺧرى ﯾﻌﺎﻧﻲ ﻣﻧﮭﺎ اﻟﻣرﯾض أو ﯾﻌﺎﻧﻲ ﻣﻧﮭﺎ‬
- Any chronic disease present like hypertension, diabetes etc
‫أي ﻣرض ﻣزﻣن ﻣوﺟود ﻣﺛل ارﺗﻔﺎع ﺿﻐط اﻟدم واﻟﺳﻛري وﻣﺎ إﻟﻰ ذﻟك‬
- Past hospitalizations and past surgeries ‫دﺧول اﻟﻣﺳﺗﺷﻔﻰ واﻟﻌﻣﻠﯾﺎت اﻟﺟراﺣﯾﺔ اﻟﺳﺎﺑﻘﺔ‬
- Medications if any taken in the past (dosage and duration)
‫اﻷدوﯾﺔ إن وﺟدت ﻓﻲ اﻟﻣﺎﺿﻲ (اﻟﺟرﻋﺔ واﻟﻣدة‬
- Allergies ‫اﻟﺣﺳﺎﺳﯾﺔ‬
- Pediatric: Birth history, Developmental Milestones, Immunizations
‫ اﻟﺗطﻌﯾﻣﺎت‬، ‫ ﻣراﺣل اﻟﺗطور‬، ‫ ﺗﺎرﯾﺦ اﻟﻣﯾﻼد‬:‫طب اﻷطﻔﺎل‬
- Gynae/Obstetric history of female ‫ﺗﺎرﯾﺦ اﻟوﻻدة ﻟﻺﻧﺎث‬
5. Family history
- It is important to establish whether there are any genetically
transmitted diseases within families.
‫ﻣن اﻟﻣﮭم ﺗﺣدﯾد ﻣﺎ إذا ﻛﺎﻧت ھﻧﺎك أي أﻣراض ﻣﻧﻘوﻟﺔ وراﺛﯾًﺎ داﺧل اﻟﻌﺎﺋﻼت‬
- Any illness run in thefamily? ‫أي ﻣرض ﯾﺳري ﻓﻲ اﻟﻌﺎﺋﻠﺔ؟‬
- Similar history in the family. ‫ﺗﺎرﯾﺦ ﻣﻣﺎﺛل ﻓﻲ اﻷﺳرة‬
- Parents and siblings suffering with any chronic illness.
‫ﯾﻌﺎﻧﻲ اﻟواﻟدان واﻷﺷﻘﺎء ﻣن أي ﻣرض ﻣزﻣن‬
- Parents if died, how old and what they died of.
‫ ﻛم ﻋﻣر و ﻣﺎ ﺳﺑب اﻟوﻓﺎة‬، ‫إذا اﻟواﻟدان ﻣوﺗﻰ‬
- You should be able to collect relevant family history depending
upon the present illness.
‫ﻗﺎدرا ﻋﻠﻰ ﺟﻣﻊ اﻟﺗﺎرﯾﺦ اﻟﻌﺎﺋﻠﻲ ذي اﻟﺻﻠﺔ اﻋﺗﻣﺎدًا ﻋﻠﻰ اﻟﻣرض اﻟﺣﺎﻟﻲ‬
ً ‫ﯾﺟب أن ﺗﻛون‬
- Example, Patient has come due anemia. ‫ ﻟﻘد ﺣﺎن اﻟﻣرﯾض ﺑﺳﺑب ﻓﻘر اﻟدم‬، ‫ﻋﻠﻰ ﺳﺑﯾل اﻟﻣﺛﺎل‬
- Try to rule out sickle cell, thalasemia/ Glucose 6 phosphate
dehydrogenase deficiency.
‫ ﻓوﺳﻔﺎت دﯾﮭﯾدروﺟﯾﻧﯾز‬6 ‫ ﻧﻘص اﻟﺟﻠوﻛوز‬/ ‫ اﻟﺛﻼﺳﯾﻣﯾﺎ‬، ‫ﺣﺎول اﺳﺗﺑﻌﺎد ﻓﻘر اﻟدم اﻟﻣﻧﺟﻠﻲ‬
 6. Socioeconomic history
- Smoking history - amount, duration and type ‫ اﻟﻛﻣﯾﺔ واﻟﻣدة واﻟﻧوع‬- ‫ﺗﺎرﯾﺦ اﻟﺗدﺧﯾن‬
- Drinking history - amount, duration and type ‫ اﻟﻛﻣﯾﺔ واﻟﻣدة واﻟﻧوع‬- ‫ﺗﺎرﯾﺦ اﻟﺷرب‬
- Any drug addiction ‫أي إدﻣﺎن ﻟﻠﻣﺧدرات‬
- Sexual history if suspected STI
‫اﻟﺗﺎرﯾﺦ اﻟﺟﻧﺳﻲ ﻓﻲ ﺣﺎﻟﺔ اﻻﺷﺗﺑﺎه ﻓﻲ اﻹﺻﺎﺑﺔ ﺑﺎﻷﻣراض اﻟﻣﻧﻘوﻟﺔ ﺑﺎﻻﺗﺻﺎل اﻟﺟﻧﺳﻲ‬
- Occupation, social and education background, financial situation
‫ اﻟوﺿﻊ اﻟﻣﺎﻟﻲ‬، ‫ اﻟﺧﻠﻔﯾﺔ اﻻﺟﺗﻣﺎﻋﯾﺔ واﻟﺗﻌﻠﯾﻣﯾﺔ‬، ‫اﻟﻣﮭﻧﺔ‬
7. System Review
General Cardiovascular ‫اﻟﻘﻠب واﻷوﻋﯾﺔ اﻟدﻣوﯾﺔ‬
- Weakness ‫ﻋﺎم‬ - Chest pain ‫أﻟم ﺻدر‬
- Fatigue ‫ﺿﻌف‬ - Paroxysmal Nocturnal Dyspnoea
‫ﺗﻌب‬ ‫ﺿﯾﻖ اﻟﺗﻧﻔس اﻟﻠﯾﻠﻲ اﻻﻧﺗﯾﺎﺑﻲ‬
- Anorexia
‫ﻓﻘدان اﻟﺷﮭﯾﺔ‬ - Orthopnoea ‫ﺗﻘوﯾم اﻟﻌظﺎم‬
- Change of weight ‫ﺗﻐﯾر ﻓﻲ اﻟوزن‬
- Short Of Breath ‫ﻗﺻر اﻟﻧﻔس‬
- Fever ‫ﺣﻣﻰ‬ - Cough/sputum ‫ اﻟﺑﻠﻐم‬/ ‫اﻟﺳﻌﺎل‬
- Lumps ‫اﻟﻛﺗل‬ ‫اﻟﺧﻔﻘﺎن‬
- Palpitations
- Night sweats ‫ﺗﻌرق ﻟﯾﻠﻲ‬ ‫زرﻗﺔ‬
- Cyanosis
Gastrointestinal/AlimentarY ‫ اﻟﻐذاء‬/ ‫اﻟﺟﮭﺎز اﻟﮭﺿﻣﻲ‬
- Appetite (anorexia/weight change) ‫ ﺗﻐﯾر اﻟوزن‬/ ‫اﻟﺷﮭﯾﺔ (ﻓﻘدان اﻟﺷﮭﯾﺔ‬
- Diet ‫ﺣﻣﯾﺔ‬
- Nausea/vomiting ‫ ﻗﻲء‬/ ‫ﻏﺛﯾﺎن‬
‫ اﻧﺗﻔﺎخ اﻟﺑطن‬/ ‫ ﺣرﻗﺔ ﻓﻲ اﻟﻘﻠب‬/ ‫ﻗﻠس‬
- Regurgitation/heart burn/flatulence
‫ﺻﻌوﺑﺔ ﻓﻲ اﻟﺑﻠﻊ‬
- Difficulty in swallowing ‫ اﻧﺗﻔﺎخ ﻓﻲ اﻟﺑطن‬/ ‫أﻟم‬
- Abdominal pain/distension ‫ﺗﻐﯾﯾر ﻋﺎدة اﻷﻣﻌﺎء‬
- Change of bowel habit ‫ ﻣﯾﻠﯾﻧﺎ‬، ‫ﻗﻲء اﻟدم‬
- Haematemesis, melaena ‫اﻟﯾرﻗﺎن‬
- Jaundice

Genital system ‫اﻟﺟﮭﺎز اﻟﺗﻧﺎﺳﻠﻲ‬

- Pain/ discomfort/ itching ‫ ﺣﻛﺔ‬/ ‫ ﻋدم راﺣﺔ‬/ ‫أﻟم‬
- Discharge ‫اطﻼق‬
- Unusual bleeding ‫ﻧزﯾف ﻏﯾر ﻋﺎدي‬
Respiratory System ‫اﻟﺟﮭﺎز اﻟﺗﻧﻔﺳﻲ‬
- Cough(productive/dry) ‫ ﺟﺎف‬/ ‫ﺳﻌﺎل (ﻣﻧﺗﺞ‬
- Sputum (colour, amount, smell) ‫ اﻟراﺋﺣﺔ‬، ‫ اﻟﻛﻣﯾﺔ‬، ‫اﻟﺑﻠﻐم (اﻟﻠون‬
- Haemoptysis ‫ﻧﻔث اﻟدم‬
- Chest pain ‫أﻟم ﺻدر‬
‫ ﺿﯾﻖ اﻟﺗﻧﻔس‬/ ‫ﺿﯾﻖ اﻟﺗﻧﻔس‬
- Shortness of breath/Dyspnoea
‫ﺳرﻋﺔ اﻟﺗﻧﻔس‬
- Tachypnoea ‫ﺑﺣﺔ ﻓﻲ اﻟﺻوت‬
- Hoarseness ‫ﺻﻔﯾر‬
- Wheezing
Musculoskeletal System ‫اﻟﺟﮭﺎز اﻟﻌﺿﻠﻲ اﻟﮭﯾﻛﻠﻲ‬
- Pain muscle, bone, joint ‫آﻻم اﻟﻌﺿﻼت واﻟﻌظﺎم واﻟﻣﻔﺎﺻل‬
- Swelling ‫ﺗورم‬
- Weakness/movement ‫ ﺣرﻛﺔ‬/ ‫ﺿﻌف‬
- Deformities ‫ﺗﺷوھﺎت‬
Nervous System ‫اﻟﺟﮭﺎز اﻟﻌﺻﺑﻲ‬
- Visual/Smell/Taste/Hearing/ Speech ‫ ﻛﻼم‬/ ‫ ﺳﻣﻊ‬/ ‫ ﺗذوق‬/ ‫ ﺷم‬/ ‫ﺑﺻري‬
- Head ache ‫ﺻداع اﻟراس‬
- Fits/Faints/Black outs/loss of con sciousness (LOC)
‫ ﻓﻘدان ﻟﻠوﻋﻲ‬/ ‫ إﻏﻣﺎء‬/ ‫ إﻏﻣﺎء‬/ ‫ﻧوﺑﺎت‬
- Muscle weakness/ numbness/ paralysis ‫ ﺷﻠﻠﮭﺎ‬/ ‫ ﺗﻧﻣﯾﻠﮭﺎ‬/ ‫ﺿﻌف اﻟﻌﺿﻼت‬
- Abnormal sensation ‫إﺣﺳﺎس ﻏﯾر طﺑﯾﻌﻲ‬
- Change of behaviour or psyche ‫ﺗﻐﯾﯾر اﻟﺳﻠوك أو اﻟﻧﻔس‬
Urinary System ‫اﻟﺟﮭﺎز اﻟﺑوﻟﻲ‬
- Frequency ‫ﺗﻛرر‬
- Dysuria ‫ﻋﺳراﻟﺑول‬
- Urgency ‫اﻻﺳﺗﻌﺟﺎل‬
- Hesitancy ‫ﺗردد‬
- Terminal dribbling ‫ﺗﻧﻘﯾط ﻓﻲ اﻟﻧﮭﺎﯾﺔ‬
- Nocturia ‫اﻟﺗﺑول اﻟﻠﯾﻠﻲ‬
- Back/loin pain ‫ اﻟﺧﺎﺻرة‬/ ‫آﻻم اﻟظﮭر‬
- Incontinence ‫ﻏﯾر ﻣﺳﺗﻣر‬ ‫ اﻟﻛﻣﯾﺔ‬/ ‫ اﻟﻠون‬:‫ﺻﻔﺎت اﻟﺑول‬
- Character of urine:color/ amount (polyuria) & timing ‫(اﻟﺗﺑول) واﻟﺗوﻗﯾت‬
- Fever ‫ﺣﻣﻰ‬