Taking a Clinical History 171

Table 1. Typical clinical history chart

Surname (1st): Hall Surname (2nd): First name(s): Kevin
Age: 32 Sex: M Marital status: M
Occupation: Truck driver
Present complaint: Frontal headaches 3/12 a. Worse in a.m. ªDullº b, ªthrobbingº c.
Relieved by lying down.
Also c/o d progressive deafness.
O/E e:
General condition: Obese, 1.65 m tall, 85 kg weight
f
ENT : Wax g ++, both sides
RS h: NAD i
CVS j: Pk 80/min reg l, BP m 180/120, HS n Normal
GIS o:
GUS p:
CNS q: Fundi r normal
Immediate past history: Weight gain
Points of note: None
s
Investigations :
Urine -ve t for sugar and albumin
Retinoscopy
Diagnosis: Hypertension
Management:
Date: 26/03/99 Signature: Peter Weiss MD.

a
3/12 For 3 months (similarly, 6/52 6 weeks and 4/7 4 days).
b
Dull ªA dull sort of acheº. Not felt distinctly. Not sharp.
c
Throbbing Beating more rapidly than usual.
d
c/o Complains of.
e
O/E On examination.
f
ENT Ear±nose±throat.
g
Wax Wax within the external auditory canal.
h
RS Respiratory system.
i
NAD Nothing abnormal detected, also Non-apparent distress.
j
CVS Cardiovascular system.
k
P Pulse.
l
reg Regular (other: SR Sinus rhythm).
m
BP Blood pressure.
n
HS Heart sounds.
o
GIS Gastrointestial system.