What is Medical History ?

It is the report that includes the personal and medical information about the
condition of the patient that help us to reach the right diagnosis and treatment.

* The process requires patience, care and understanding to yield the key information
leading to correct diagnosis and treatment.
* Types of questions:
1- Open Question
2- Close Question
3- Reflexive Question
4- Clarifying Question
What is the medical history include ?
1. Personal informations
2. Chief complaint and duration
3. History of presenting illness
4. Past medical history
5. Past surgical history
6. Gynecological and obstetric history
7. Treatment (Drug) history
8. Personal ,Family and Social history
9. Review of other systems
 ‫‪1. Personal Informations‬‬
‫‪1- Name‬‬
‫صائدةذاالدمذاغهذاوالذغؾينذجدورذتواصلذععذادلرؼضذحؿىذغؽدرذغصقحؾهذبإمسهذوذغؿواصلذوؼاهذادفلذوذخنؾقهذ‬
‫عرتاحذعنذؼدوظفذوذطذظكذالشراضذضاغوغقةذوذادارؼةذوذممؽنذعراتذؼدظلذسؾىذدؼاغةذاظشخصذوذػذاذراحذغذطرذ‬
‫ذؾونذغدؿػادذعـهذبعدؼن‪.‬ذذ‬
‫‪2- Age‬‬
‫طلذصؽةذسؿرؼةذاطوذاعراضذععقـةذتصقؾفهذصؾذظكذعفمذغعرفذاظعؿرذحؿىذغعرفذبشـوذغػؽرذذ‬
‫عـالذاغـىذسؿرػهذ‪35-25‬ذدـهذوذسدػهذعـالذصدذورمذصغريذمبـطؼةذاظرضؾةذ‪,‬ذػـاذعؾاذرةذراحذاصؽرذبدواظفذاظغدةذ‬
‫اظدرضقةذالنذػيذذائعةذسـدذاالغاثذبفايذاظػؽةذاظعؿرؼة‪.‬ذ‬
‫)‪3- Sex (Gender‬‬
‫ػـاذشاظؾاذعاذغدالذسـهذظؽنذاذاذطانذرػلذرضقعذوذعاذواضحذاجلـسذغدالذوذطذظكذصائدتهذاغهذاطوذاعراضذتصقبذ‬
‫اظرجالذوذاطوذتصقبذاظـداءذوذمبرورذاظوضتذراحذغؽومذغعرفذػاالعور‪.‬ذ‬
‫‪4- Address‬‬
‫سـوانذادلرؼضذعفمذجداذالنذاولذذيذراحذاسرفذادلرؼضذداطنذبادلدؼـةذاوذباظرؼفذ‪,‬ذثاغيذذيذممؽنذاذاذسـديذ‬
‫عـطؼةذعوبوئةذبػدذعرضذععنيذػمذراحذؼدفلذسؾقهذاظؿشخقصذوذطذظكذدلراساةذزروفذادلرؼض‪.‬ذ‬
‫‪5- Occupation‬‬
‫عراتذاطوذاعراضذترتؾطذباسؿالذععقـةذعـالذاظيذؼشؿغؾونذمبعاعلذادلطاطذوذباالصؾاغذوذادلوادذاظؽقؿقائقةذتؽونذ‬
‫صرصةذاصابؿفمذباعراضذاجلفازذاظؿـػديذاطـرذعنذشريػمذوذطذظكذاطوذعرضذامسهذ(عرضذاظـداصني)ذؼصقبذاظيذ‬
‫ؼشؿغؾونذباظصوفذوذػايذاظدواظف‪.‬ذ‬
‫)‪6- Marital state (Married / single / divorced / Widow‬‬
‫احلاظةذاظزوجقةذعفؿهذحؿىذغعرفذاذاذاطوذ )‪Sexual Transmitted Diseases (STD‬ذاظيذػيذ‬
‫االعراضذادلـؿؼؾةذجـدقاذوذطذظكذاذاذاطوذاعراضذاخرىذاهلهذسالضةذباظزواج‪.‬ذ‬
‫‪7- Blood Group‬‬
‫رؾعاذعفؿهذجداذحؿىذاذاذادلرؼضذاحؿاجذغؼلذدمذغعرفذذـوذغـؼؾه‪.‬ذ‬
‫‪8- Religion‬‬
‫اطوذاعراضذععقـةذتؽونذعـؿشرةذوراثقاذسـدذدؼاغةذععقـةذاوذعـالذاطوذروائفذععقـةذترصضذغؼلذاظدم‪.‬ذ‬
9- Date of admission ‫تارؼخذاظدخولذظؾؿدؿشػى‬
10- Date of history taking‫تارؼخذاخذذاهلدرتيذذذذذذذذذذذذذذذذذذذذذذذذذذذذذذذذذذذذذذذذذذذذ‬
11- Source of information (Relatives) ‫عصدرذادلعؾوعاتذعنذادلرؼضذاوذعنذاضرباءذادلرؼضذ‬

)‫(كل هذه المعلومات ال تكتب بشكل نق اط و انما يفضل ان تٌصاغ على شكل قصة قصيرة‬

Fatima Hussein Ali , 75 years old female , live in Hilla – Al Mahaweel , house wife ,
widow , she is muslim and unknwn blood group , she admitted to the hospital on
23\8\2022 and the history taking from her daughter on 25\8\2022 .
 2. Chief Complaint (C.C) and Duration
The main problem(s) that made the patient seeks the medical advice and the
duration of this(ese) compliant(s).
Or: the main cause that make the patient consult the doctor.
* It is preferable to mention one chief complaint.
* We can mention two C.C if they are in the same system (Example: Diarrhea and vomiting)
* Record patient’s words and don’t mention medical terms. For example say
shortness of breath and not dyspnea, frequent bowel motions rather than diarrhea.
* We can say (prior to admission) for the duration of C.C
Example: shortness of breath for 10 days duration.
or: shortness of breath for 10 days prior to admission.
.‫ذغؼصدذبقفهذادلدةذاظيتذادؿؿرذبفاذاظعرضذضؾلذاظذػابذاىلذاظطؾقبذاوذادلدؿشػى‬Duration‫*ذالذ‬
 3. History of presenting illness
In this section, the student needs to tell the story of patient’s
compliant in a way that helps to narrow the differential
diagnosis of the underlying cause.
‫ذ‬
‫ذغذطرذاجلؿؾةذاظؿاظقةذوذبعدػاذغؽؿلذباضيذاظؿػاصقلذ‬Presenting illness ‫ؼػضلذيفذبداؼةذالذ‬
The condition started as shortness of breath for 10 days duration
.‫ذعـلذعاذراحذغاخذػهذالحؼا‬SOB ‫وذابؾشذاذطرذتػاصقلذالذ‬
What is History of presenting illness consist of ?

1. Analysis of C.C
2. Review of the system that have the C.C
3. Hospitalized course
4. General questions
5. The condition of the patient now
 ‫‪1. Analysis of C.C‬‬

‫بفذاذاظؼدمذراحذغذطرذطؾشيذخيصذالذ ‪C.C‬ذباظؿػاصقلذادلؿؾةذوذاؼضاذبدونذ‬
‫عصطؾحاتذرؾقةذالنذػذاذطالمذادلرؼضذوذادلرؼضذؼؿؽؾمذظغةذساعقة‪.‬ذ‬
‫رؾعاذطلذ ‪C.C‬ذراحذتؽونذادؽؾؿهذخاصةذبيذوذختؿؾفذسنذشريةذظؽنذاطوذ‬
‫ذغالتذتؽونذعشرتطةذوذػذاذراحذغشوصهذباظؿػصقلذباظدالؼداتذاظؼادعة‪.‬ذ‬
 Analysis of pain
We use SOCRATES to make it easier :
Site ( somatic pain well localized , visceral pain more diffuse )
Onset (sudden or gradual)
Character )sharp , dull , burning , tingling , stabbing , heaviness …(
* Use patient own description rather than offering suggestions.
Radiation
Associated symptoms (like nausea and vomiting)
Timing/ Duration(of each attack) and frequency (continuous OR intermittent)
Exacerbating and relieving factors
Severity (by affecting sleep and daily activities)
 Difference between Radiated and Referred Pain
Radiation is the extension of the pain to
another site whilst the initial pain persist.
* For example,
a posterior penetrating duodenal ulcer
usually have a persistent pain in the
epigastrium, but sometimes the pain spreads
through the abdomen to the back.
* The extended pain usually has the same
character as the initial pain.
* A pain may occur in one site, disappear,
and then reappear in another.
This is not radiation: it is a new pain in
another place.
Referred pain is a pain which is felt at
a distance from its source.
* For example,
Diaphragmatic pain will cause a pain
which is felt at the tip of the shoulder.
* A referred pain is caused by the
inability of the central nervous system to
distinguish between visceral and somatic
sensory impulses.
* From the patient’s viewpoint, the pain
is where they feel it – the fact that the
source is some distant organ does not
concern them.
 Symptoms of Cardiovascular system
1. Chest pain (questions of pain)
2. Palpitation (Awareness of heart beats)
Onset, Duration, Frequency
Rapid or slow, Regular or not ?
Aggravating factors like coffee or alcohol drinking , certain medication,
exercise or chest infection
Terminated spontaneously or with medication
Associated symptoms like syncope , dizziness , chest pain or
polyuria ( feature of supraventricular tachycardia ”SVT” (.
* One of most important extra cardiac causes of palpitation is Hyperthyroidism
3. Shortness of breath
Onset and duration
Severity ( in the slide No. 20 )
Aggravating factors :
lying flat, After how long ?
with exercise ? After how many meters ?
cold weather, dust or smoke ?
How many pillow you need at night ?
Relieving factors
Associated features like fever, cough, wheeze, weight gain or loss.
Paroxysmal nocturnal dyspnea: is sudden breathlessness which wakes the patient
from sleep chocking or gasping for air.
Orthopnea: is dyspnea on lying flat and is a sign of advanced heart failure
Intermittent claudication: is pain felt in the legs on walking due to arterial
insufficiency.
Cyanosis: is bluish discoloration of skin and mucous membrane, occurs when
absolute concentration of deoxygenated hemoglobin > 50 g/l. TWO Types:
Central cyanosis: seen at the tongue and lips
Peripheral cyanosis: seen in hands, feet and ears
Syncope/ pre-syncope: loss of consciousness due to inadequate cerebral
perfusion.
Leg swelling: suggest oedema that suggest heart failure
 Symptoms of Respiratory System
1. Cough
Duration (acute less than 3 weeks/ sub-acute from 3 to 8 weeks/ chronic more
than 8 weeks) and frequency
Is there any particular time of day when the cough is the worst (nocturnal cough
means asthma, gastro esophageal reflex disease (GERD) and left ventricular
failure while early morning cough occurs in chronic bronchitis)
Aggravating factors like dust, animals, deodorant, cold weather, exercise or
cigarette smoke in asthma/ eating and like lying flat in GERD.
Is it progressive ?
Is there any seasonal variation ?
Painful or not ?
Productive or not ?
2. Sputum
* Color
Serous: acute pulmonary edema
Mucoid: chronic bronchitis/ asthma
Purulent: yellow: acute Broncho pulmonary infection and asthma
Green: bronchiectasis and lung abscess
Rusty: pneumococcal pneumonia
* Amount: large amount is seen in bronchiectasis, broncho-pleural fistula
* Smell : foul smell indicates bronchiectasis and lung abscess
* Hemoptysis (productive cough with blood)
Onset, duration and frequency
Amount
Frank blood or streaks the sputum
 * Shortness of breath
Breathlessness when lying flat (orthopnea)
Breathlessness on sitting up (platypnea)
Breathlessness when lying on one side (trepopnea)
* Chest pain
* cyanosis
* Wheeze: is a high pitched whistling sound caused by air passing through
narrowed small airways, occur during the expiration.
* Strider: inspiratory musical sound due to upper airway narrowing.
* Hoarseness of voice ‫صوتهذعؾحوحذذذذذذذذذ‬
‫ *ذ‬Nasal symptoms like rhinorrhea ‫رذح‬
‫ذمباذاغهذاطوذاسراضذعؿشابفهذبنيذاجلفازذاظؼؾيبذاظوسائيذوذاجلفازذاظؿـػديذصفايذاالسراضذغذطرػهذعرةذوحدةذصؼطذبواحدذ‬:‫عالحظة‬
‫ذ‬.‫عنذاالجفزةذوذعاطوذداسيذغؽررػهذ‬
To determined the severity of SOB
 Symptoms of Gastrointestinal System
* Mouth
Painful mouth \ teeth problems
Water brush (increase salivation)
Dry mouth (decrease salivation)
Halitosis (foul smell)
* Dysphagia
Onset and duration
Where is the site of dysphagia is it at the pharynx or retrosternal (in the esophagus) ?
Painful or not? If painful called (odynophagia)
For solid or liquid or both ?
Progressive or intermittent ?
Is there any heart burn or regurgitation ?
* Nausea or vomiting
Color \ taste \ smell
Content ( food particles ) ?
How many times the patient vomited (frequency) ?
What is the amount ?
Does it related to the meal ? At early morning ? At night ?
Does the vomiting associated with nausea, abdominal pain or dyspepsia (heart burn) ?
Does that pain relieved by vomiting ?
Is it projectile or not ?
Is the vomitus stained with bile, blood or feculent ?
Note: Early morning vomiting suggest (pregnancy , alcohol intake , increase intra cranial
pressure)
* Dyspepsia (feeling of acidity) , (feeling of indigestion)
* Hematemesis (vomiting with blood)
Is there any previous history of hematemesis or peptic ulcer diseases?
Is there any history of smoking, non-steroidal anti-inflammatory drugs (NSAID), steroids
or alcohol ingestion
Is there any history of liver disease?
Does the hematemesis preceded by retching? ‫باظعاعقةذغؽولذ(دنوظع)ذذذذذذ‬
Does the blood appeared in the very first vomit ?
How many times (frequency) ? What is the amount of blood?
Was it fresh or coffee ground?
What is the color of the stool? Why we asked this question?
* Abdominal pain/ abdominal distension
* Tenesmus (need to defecate but the bowel is empty)
* Flatulence (Abdominal distention due to gases accumulation)
* Crumps (Abdominal distention due to stool accumulation)
* Jaundice (Yellowish discoloration of skin , sclera and mucous membrane)
Onset: Sudden or gradual?/ recurrent or not ?
Any right upper quadrant pain (liver) or abdominal pain elsewhere ?
Is there any fever ?
‫طدعات‬
Itching / ecchymosis / change in urine or stool color ?
Is there any travel history or contact with jaundiced patient like:
(hepatitis A)/ blood transfusion, previous operation, Intravenous drug addiction
or tattooing (hepatitis B and C) ?
Is there any family history of hemolytic anemia
Is there any sexual contact outside the marriage (if the patient is married) ?
* Diarrhea (Frequent bowel motion) (more than 3 bowel movements daily)
Color \ content
Acute, chronic or intermittent (frequency) ?
Is the stool liquid or semisolid ?
Is it infrequent with large volume (small intestine) or frequent with small volume (large intestine)
Does it associated with fever ?
Does it affect patient’s sleep ? to differentiate the:
Organic diarrhea (there are detectable physical or biochemical changes within the cells, tissues, or
organs of the body) from
Functional diarrhea (loose stool consistency and chronicity)
Is there any blood, pus or mucous with the stool?
Is there any tenesmus , urgency(need to defecation quickly) or incontinence (uncontrolled
defecation)
Ask about drug history
* Constipation (infrequent bowel motion)
no bowel movement for 4 days or more
* Melena
is passing tarry (shiny black) stool with characteristic odor, caused by upper
gastrointestinal tract bleeding.
* Rectal bleeding
* Is the blood mixed with stool or just streaking ?
* Is it painful?
* Is it offensive or not ? ‫صعبذباخلروجذاوذالذ؟‬
* Does it associated with hematemesis ? Why we ask this question ?
Causes of abdominal distention
 Symptoms of Genitourinary system
* Loin pain/ suprapubic pain
*Dysuria: painful or burning micturition
* Polyuria: is defined as a urine volume exceeds 3 liters per day
caused by diabetes mellitus ,diabetes insipidus…etc
* Oliguria: is defined as being present when less than 500 ml urine is passed per day
* Anuria: is defined as passing less than 50 ml urine per day OR complete
absence of urine usually reflect urinary tract obstruction
* Frequency: is micturition more often than patient’s expectations
* Urgency
* Incontinency (stress?/ urge?): involuntary leakage of urine
Stress Incontinence: urine leakage with increase abdominal pressure
occurs in women due to weakness of the pelvic floor, usually following childbirth.
Urge Incontinence : urge to pass urine followed by involuntary leakage
Urge incontinence occurs when the detrusor is overactive.
* Nocturia: is defined as waking at night to void urine
* Bed wetting: Micturition during sleep
* Hematuria: presence of blood in the urine,
Non visible , microscopic (detected on urinalysis) OR
Visible , macroscopic can be seen by naked eye
* Hesitancy = Urine retention = difficulty starting urination
* Poor stream
* Post-micturition dribbling
* Urethral discharge
Causes of Urine Incontinency
 Symptoms of Central nervous system
* Headache: in addition to general questions of pain (SOCRATES) , in case of
headache you need to ask these extra question:
Is it the first episode of headache or have there been previous episodes?
If it is a recurrent problem, are all the episodes of similar type? quality? or severity?
Is the pain unilateral or bilateral?
Is the headache affecting the sleep or lifestyle of the patient (Severity) ?
Associated features: is it associated with fever, neck pain, loss of consciousness,
abnormal movements, limb weakness, scalp pain or any visual symptoms?
Does it change with changing position? it get worse on wakening or lying down ?
Is the pain associated with vomiting ? (features of increased intracranial pressure)
* Loss of consciousness/ disturbed consciousness
* Vertigo: a false sense of movement of oneself or the environment; very important to ask about
associated unsteadiness, tremor, hearing impairment, ear pain or specific precipitation by head
movement.
* Dizziness (Light headed) ?
* Any weakness? * Any paraesthesia? ( feeling of pins and needles )
* Abnormal speech
* Abnormal movement
Tremor (unilateral OR bilateral ? at rest or when you stretch your hand ?
is it progressive or no ? does it involve the head and tongue or not ?
*Dance-like movement (chorea) *Change in behavior
* Loss of memory * Change in vision/ taste/ hearing
* Bladder, bowel and functional disturbances * Gait/ balance
* Fit/ seizure (mostly the history is taken from a witness and the patient)
Is it the first time?
Stage 1 (Before the episode)
What happened before the episode ? (pre-ictal)
What are the aggravating factors like sleep deprivation, fatigue or alcohol withdrawal ?
Any abnormal feeling(s) preceded the fit like epigastric pain, funny smelling sensation ?
Aura? (photophobia and phonophobia)
Stage 2 (During the episode)
What happened during the abnormal episode ? (ictal)
Any loss of consciousness ?
Any abnormal movement ? which part of the body is involved ?
For how long the convulsion continued ?
Any change in patient’s color )cyanosis) ?
Any involuntary urination or defecation ?
Has there been any tongue bite or Injury ?
Stage 3 (After the episode)
What happened after the event (post-ictal)?
Any associated features like headache, fever,
memory disturbance, limb weakness
or paresthesia ?
 Symptoms of Musculoskeletal System
*Arthralgia: joint pain
* Myalgia: muscle pain
* Bone pain
Symptoms of Endocrine system
* Joint swelling
* Limitation of joint movement *Heat OR cold intolerance ?
* Muscle weakness (proximal, distal or * Excessive thirst (polydipsia) ?
generalized) * Change in sweating ?
* Gait disturbance
 ‫‪2. Review of the system that have the C.C‬‬

‫بفذاذاجلزءذعنذالذ ‪ Presenting Illness‬راحذغدألذسنذاالسراضذعالذ‬

‫اظددؿمذاظيذطانذبيذالذ‪C.C‬ذ‪,‬ذؼعينذعـالذطانذادلرؼضذجايذظؾؿدؿشػىذالنذسـدهذ‬
‫‪diarrhea‬ذػـاذبفايذاظػؼرةذراحذادويذ ‪Review‬ذظالسراضذعنذاجلفازذ‬
‫اهلضؿيذ‪,‬ذوذطذظكذػـاذعاذغذطرذعصطؾحاتذرؾقةذوذامناذظغةذادلرؼضذ‪.‬ذ‬
 ‫‪3. Hospitalized course‬‬
‫‪The student need to mention any investigation/ procedure(s) has been done‬‬
‫‪and treatment prescribed to the patient during this hospital admission.‬‬
‫ػـاذراحذغذطرذطلذاظؿػاصقلذادلؿؾةذعنذاظؾحظةذاظيذدخلذبقفهذادلرؼضذظؾؿدؿشػىذحلدذعاذاحـهذذػـاهذوذداذغاخذذعـهذاهلدرتيذ‪.‬ذ‬
‫وذػايذاشؾبذادلصطؾحاتذاظيذحنؿاجفهذػـاذ‪:‬ذ‬
‫‪CT Scan , MRI . Ultrasound , X-ray , Blood analysis (test) , Urine test , Stool‬‬
‫‪examination , Hemofiltration , Hemodialysis , IV Fluid , Foley catheter ,‬‬
‫‪Suturing , Endoscopy , Colonoscopy , Sigmoidoscopy , catheterization‬‬
‫مالحظة‪ :‬اذاذطانذادلرؼضذعـؼولذعنذعدؿشػىذاىلذعدؿشػىذاخرذادؿعؿلذطؾؿةذ ‪Transferred‬ذاعاذاذاذطانذعـؼولذعنذردػةذ‬
‫اىلذردػةذاخرىذادؿعؿلذطؾؿةذ ‪Shifted‬ذ‪.‬‬
‫مالحظة‪ :‬عوذصؼطذاذطرذاظؿحاظقلذوذاالعورذاظيذدواػهذوذامناذحؿىذاذطرذايذذيذؼصريذوؼاهذحؿىذظوذطانذعـالذصؼدانذوسيذ‪ .‬ذ‬
 4. General questions
* Fever
* Appetite
* Weight change
* Energy
* Sleep
* Mood
Note: Always we put the Positive findings at first and then the negative findings.
 Analysis of Fever
SOCRATES
1- Subjective or objective
2- Onset (Sudden , Gradual)
3- Character (continuous , intermittent , remittent , relapsing)
4- Relieving factors (compresses , paracetamol)
5- Associated symptoms ( Chills , Rigor , Sweating , Fit )
6- Timing ) Morning , Night …etc(
7- Exacerbating factors
8- Severity
 5. The condition of the patient now

Example:
The condition of the patient now is very good after
treatment and he will leave the hospital today at night.
 4. Past Medical History
Here we asking about the following:
1- Chronic Diseases (Hypertension, diabetes mellitus, tuberculosis, asthma, chronic obstructive airway
disease, ischemic heart disease , stroke , epilepsy , cancer ……etc )
Since when you have this disease ?
How did you discover it ?
Did you take medications for this disease ?
Controlled or complicated disease ?
2- Previous admission to hospital with same condition ?
3- Previous admissions to hospital ?
How many times ?
What is the reason of admission ?
4- Childhood illnesses
(measles , whooping cough , mumps , rickets , rheumatic fever)
 5. Past Surgical History
Here we asking about the following:
1- Previous Operations (surgeries)
Name ?
Date ?
Type ? (Open OR by laparoscope )
Who was the surgeon ?
Which hospital ?
Type of anesthesia ? (Local OR General)
How long the patient stayed in the hospital after the procedure ?
Any complications ?
2- History of biopsy taking like liver or kidney biopsy ?
 6. Gynecological and obstetric history
Here we asking about the following: (ONLY FOR FEMALES)
1- Number of pregnancies
Any complications with pregnancy ( hypertension , DM )
2- Number of deliveries
At home OR Hospital ?
Normal vaginal delivery or caesarean section ?
Any complications of the caesarean section
3- Number of still birth (after 20 weeks) / number of abortions (before 20 weeks)
 Menstrual history
Here we asking about the following: (ONLY FOR FEMALES)
1- Menarche: the age when the period starts , Frequency (regular or irregular)
How many days does it last?
What is the amount of blood, heavy or not? Is there any clots?
2- Oligomenorrhea: Period occurs in intervals longer than 35 days and/or being particularly light (with
little amount of blood)
3- Menorrhagia : Heavy menstrual bleeding
4- Dysmenorrhea: Pain prior or during the period
5- Amenorrhea
Primary amenorrhea: No period at all by the age of 16 years
Secondary: No period for 3 months or more in a woman who previously menstruated regularly
6- Menopause: The final spontaneous menstrual period
7- Postmenopausal bleeding: spontaneous menstrual bleeding one year after the menopause
 7. Treatment (Drug) history
Here we asking about the following:
1- Treatment for chronic diseases
Type of medication
The dose
For how long the patient is on this medication ?
Any side effects ?
2- By hand medications
3- Drug allergy
4- History of blood (or blood products) transfusion
What reason ?
How many pints ?
Was there any complications ?
5- Radiotherapy , Chemotherapy ?
6- History of Vaccination ? (If important)
 8. Personal ,Family and Social history
Here we asking about the following:
1- Marital status
2- Number of children (males and females)
3- Are there any genetic disease in the family ?
4- Ask about the parents , are they alive? how old are they?
if they are dead, ask at which age they died and why?
5- Ask about brothers and sisters
6- Any history of sudden death in the family especially at young age?
7- If there is any similar illness running in the family (inherited or infectious)
 8. Personal ,Family and Social history
Here we asking about the following:
1- Smoking ? ( details in the next slide )
2- Alcohol intake ? & amount
3- Pets and domestic animals
4- Live in urban OR rural area ?
5- Home
How many rooms/ how many persons are living there/ is the house crowded or not?
6- Water supply (tap water, pure water, river water)?
7- Travel history
8- Sexual history
 Calculating pack-years of smoking
A ‘pack-year’ is smoking 20 cigarettes a day (1 pack) for 1 year

𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑐𝑖𝑔𝑎𝑟𝑒𝑡𝑡𝑒𝑠 𝑠𝑚𝑜𝑘𝑒𝑑 𝑝𝑒𝑟 𝑑𝑎𝑦 ×𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑦𝑒𝑎𝑟𝑠 𝑠𝑚𝑜𝑘𝑖𝑛𝑔

20
For example:
a smoker of 15 cigarettes a day who has smoked for 40 years , calculating as:

15 ×40
= 30 pack – years
20
9. Review of other systems
 Medical Terms Write in the history ‫المعنى بالعربي‬

Dyspnea Shortness of breath

Palpitation Awareness of heart beats
Edema Swelling (Fluids)
Hemoptysis Coughing up blood
Cyanosis Bluish discoloration of the body
Lump Swelling
Intermittent claudication Pain in calf on walking
Coma Loss of consciousness
Vertigo Sensation of unsteadiness
Dizziness Sensation of faintness on standing
Convulsion Jerking movement of body
 Medical Terms Write in the history ‫المعنى بالعربي‬

Retention Inability to pass urine

Hesitancy Difficulty in starting urination
Terminal dribbling Difficulty in stopping urination
Urgency Rapid desire of urination
Edema of face Puffiness of the eyes or face
Xerostomia Dry mouth
Water brush Excessive salivation
Polyphagia Increase food intake
Dyspepsia Feeling of indigestion
Heart burn Feeling of burning or acidity
Regurgitation Return food to the mouth
Medical Terms Write in the history ‫المعنى بالعربي‬

Hyperhidrosis Excessive sweating

Ascites Fluid collection in the abdomen
Gynecomastia Breast enlargement in males
Parasthesia Tingling sensation
Hematemesis Vomiting up blood
Anorexia Loss of appetite
Hiccups Hiccups ‫امذاظعوايفذذ‬
Diarrhea Frequent Bowel motion
Constipation Infrequent Bowel motion
Obstipation No passage of stool or gases
Melena Black tarry stool
Medical Terms Write in the history ‫المعنى بالعربي‬

Dysphagia Difficulty in swallowing

Odynophagia Painful swallowing
Polydipsia Increase water intake
Tenesmus Feeling of incomplete defecation
Anismus Difficulty in emptying rectum
Hematochesia Rectal bleeding
Fatigue Generalized weakness of the body
Medical Surgery Name English Surgery Name
Appendectomy Removal of appendix
Cholecystectomy Removal of gallbladder
colectomy Removal of colon
Hysterectomy Removal of uterus
Thyroidectomy Removal of thyroid gland
Hernia Hernia
Tonsillectomy Removal of tonsils
Splenectomy Removal of spleen
Mastectomy Removal of breast
Gastrostomy ‫تػوؼهذادلعدةذذ‬
Duodenostomy ‫تػوؼهذاالثينذسشرذذ‬
Catheterization ‫ضدطرةذ‬