History sheet

Name: Marital Status : Married / single /

divorced ‫مطلقة‬/ Widow ‫ارملة‬
Age: years old ABO Group & RH:
Gender: male / female Date&Time of admission:
Address: Date&Time of Hx taking :
Occupation: office worker / house Date&Time of Ex :
wife / police man / personal job
( ‫) اذا اعمال حرة اكتب شنو هو بالتفصيل‬ Source Of Information :

……………………………………………………………………………………………………………………………………………………………

Chief complaint and duration ( C.C ) :

………………………………………………………………………………………………………………………………………………………………
History of present illness ( P.I ) :
 In the beginning of P.I : we must mention some chronic
diseases and it's duration if they related to chief complaint .
And mention if the patient transferred from another hospital
or shifted from another ward

E.X : Known case of (DM , HYPERTENSION ,Epilepsy , Asthma ,

ETC ) since 2005 , firstly the pt. admitted to Emergency
department at alyarmook hospital and remains 3 hours , then
he transferred to dialysis center at alkarama hospital for
hemodialysis .

In the middle of P.I : We clarify the details of C.C and involved

system

In the end of P.I : We mention the investigations( Ivx ) and

medications ( Rx ) which performed to the patient
Especially at emergency department
(X-Ray , ECG , CBC , GUE , Blood tests , blood
transfusion,I.V Fluid , injection , Oral tablets , ETC .. )
P.I ‫بعض التدريسيين ال يقبلون ذكر اسم الدواء او التحليل داخل‬
E.X : some investigations performed on him such As
Brain CT Scan and ECG And he received some
medications such As paracetamol vial and plasil amp.

We prefer ask about involved system inside P.I , but this is not a rule
Pain Hx ( SOCRATES )

Site:

Onset : gradual / sudden

Character ( Nature ) : colick / pinprick / stabbing / tearing /

squeezing / burning / heaviness / Spasmodic / Throbbing

ache : continuous – localized – mild or moderate ( Bachache )

Dull : continuous – does not stop you from daily activities ( Sore
Muscle )

Sharp : sudden & severe (localized or diffused)

Radiation:

Associated symptoms: Fever / Wt. loss or gain / sweating /

Appetite loss or gain / polydipsia / ETC..

Time ( change over time ) : Progress / decrease

Exacerbating (aggravating ) factors :

Relieving factors :

Severity : Mild – Moderate – Severe

Frequency : Constant Or Intermittent

Vomiting Hx

1- Amount
2- color
3- Content ( undigested food ? )
4- smell
5- Blood
6- Frequency
7- related to food or drink ?
8- Severity ( projectile or effortless )
9- Time : Early morning ? maybe pregnancy – alcohol – Increase ICP

Fever Hx

1- Duration  Chills : feeling of coldness during high fever ,

2- Onset sometimes it occurs alone
3- severity
 Rigor : severe chills with strong shivering
4- rigor or chills *
5- sweating

Volume , Frequency , Color , Odor , Contains

 History of Op.
Pre-Op ‫التحضيات قبل العملية‬
‫ر‬
1-Elective or Emergency
2-Fluid & Abx & Analgesics & laxatives & Nil by mouth
3-Ivx ( Blood tests & imaging&blood preparation )
4-Blood transfusion
5-Foley Cath. or NG Tube

Peri-Op ‫اثناء العملية‬

1-Duration of Op.
2-Anesthesia type & problem
3- Blood transfusion
4-Known complications during Op.
5- If the surgeon took biopsy
Post-Op. ‫بعد العملية‬
( Day 0-1-2 ‫) اهم االيام‬
1-Time of return of consciousness
Recovered smoothly from anesthesia or Regained
consciousness at ......

2-Urine 12-Fever
3-Stool 13-N & V
4-Flatus 14- Cough
5-Walking 15- SOB
6-Eating & Drinking 16- Chest pain

7-Blood transfusion 17- Leg pain

8- I.V fluid 18- Wound bleeding or discharge

9-Analgesia 19 -Dressing Change &Disinfection

10-Abx 20- Review of system associate now

11-Foley Catheter ,surgical drain , NG tube, stoma

 SYSTEMATIC ENQUIRY
( REVIEW OF SYSTEMS )

CVS Resp.
1-Chest pain 1-SOB

2-Palpitation 2- Cough (dry-productive)

3-SOB 3-sputum (amount&color)

4-Lying flat (orthopnea) 4-hemoptysis (bloody cough)

5- PND 5-wheezing
paroxysmal Nocturnal dyspnea
6-chest pain with coughing and
) ‫) يفز من النىم مختنك‬
respiration
6-Cyanosis

7-Ankle & Leg swelling

8-Claudication
 MSK
1- Joint pain (Socrates)

2- Ache : feel a constant , mild to moderate pain

3- Redness

4- Swelling

5- Locking or Stiffness
(incomplete movement of joints )

Skin
1- Itching ( Pruritus )
2- Redness ( Flare ) or rash
3- Swelling ( Wheal )
4- Lump ( size – site – mobility – pain – consistency –
pulsation )
 PAST MEDICAL HISTORY (P.M Hx )

1- Any chronic disease or disease has complications in the

future , diagnosed by Physician
‫ مو رشط مرض مزمن‬, ‫اي مرض مشخص سابقا و ممكن ان يكون له مضاعفات‬

Anesthetic problem ‫مشاكل عند التخدير‬ Angina ‫ذبحة‬

Rheumatic fever ‫حمى الروماتزم‬ MI ‫جلطة قلبية‬
TIA : Transient Ischemic Attack ‫جلطة عابرة‬ HF ) ‫فشل بالقلب( قلب‬
Stroke ‫جلطة دماغية تامة‬ HTN ‫ضغط‬
SCA : Sudden Cardiac Arrest ‫توقف القلب المفاجئ‬ DM ‫سكر‬
CKD ‫فشل كلىي مزمن‬ TB ‫سل – تدرن‬
Hepatitis ‫التهاب الكبد الفيروسي‬ Asthma ) ‫ربو ( حساسية قصبات‬
P.U.D ‫قرحة‬ Epilepsy ‫صرع‬

If there is disease , For each one determine :

1- When was it diagnosed ? ‫شوكت تشخصت‬
2- How was it diagnosed ? ‫شلون تشخصت‬
‫شلون تعالجت او بعدك ز‬
3- How has it been treated ? ‫مليم بالعالج‬

2- Pervious same symptoms or similar attack of C.C

When ? times ?

3- History of previous admission to hospital

When ? why ?
 PAST SURGICAL HISTORY ( P.S Hx )

1- Past Operations Or Endoscopy :

2- Date :
3- Hospital name & location :
4- It's complication :
5-History of previous Blood transfusion:

Drug history
1- Chronic Drug Use ? NAME ?
steroid , contraceptive , Warfarin , Heparin , Aspirin,
insulin , oral hypoglycemic , antihypertensive , etc.

2- Duration ?

3- Dose ?

4- Drug allergies ?

5- Radiotherapy , Chemotherapy , Psychotherapy ?

6- Previous significant drug side effects ?
 FAMILY HISTORY

1-Any chronic or hereditary disease in 1st degree relatives

DM // HTN // CA ( Esp. Colo-Rectal & Breast Cancers ) // TB

GOUT ( ‫ ( النقرس – داء الملوك – ارتفاع امالح مزمن‬// Hyper-cholesterolemia

Heart disease

Renal disease

Mental disease

2-Same symptoms in the family ?

3- Hx. of surgery in the family ?

4- Hx. of early death in the family : cause , date ?

5- Diseases affect more than one member of the family ?

 Social & Personal Hx

1- Housing : Own or rented house?

2- Number of rooms ?
3- Animal relationship & Pet rearing ?
(bird fanciers - psittacosis) (cattle – brucellosis ).
4 - Traveling & Activity ?
5 - worries or stresses ?
6- Diet ?
7- Exercise ?
8- Drug Addiction ? Like DIAZEPAM ( VALIUM )
- Name :
- Dose :
- Duration :

‫ز‬
‫نسبة الكحول يف كل نوع تقريبا‬ Amount By Units ‫تقريبا‬
9 - Alcohol drinking ?
Rum 60-75% - 25ml ( single small shot)
- Type ?
Whiskey 40-50%
of All spirit types = 1 unit
- Amount ? Gin 35-55%
- Duration? Vodka 40%
- 125ml of wine = 1.5 units
-Frequency ? Wine 10-15%

Beer 4-6 %
-Alcoholic liver disease ?
- 330ml of beer = 1.7 units
spirits ‫ كلها انواع من ال‬4 ‫اول‬
 10 - Smoking : Non- Smoker // Active Smoker // Ex Smoker ?
mild : 1-10 cigarettes per day
moderate: 10-20 cigarettes per day
heavy : above 20 cigarettes per day
(( only cigarettes not hookah or tobacoo or E-Cigarettes ))
Smookless Tobacoo : Cannabis – Marijuana – Hashish - Khat

‫ر ز‬
‫النيكوتي و القطران تختلف باختالف نوع الجكارة لكن هذا‬ ‫صحيح كمية‬
‫التصنيف عام‬

‫ر ز‬
Ex Smoker ? ‫ ايام تاركه فقط‬3 ‫التدخي وهو صارله‬ ‫انتبه يجوز يكلك تارك‬
(Number ? Duration Of Smoking ? )

pack – year = Number of cigarettes smoked per day x Number of years smokes / 20

If alcohol intake was : CAGE screen for problematic alcohol issues

1 unit / day for females C : Cut

2 units / day for males A : Annoying

That’s will reduce liver cirrhosis risk G : Guilty

! ‫ يونت‬100 ‫اكو ناس تشرب مرة واحدة بالشهر لكن‬ E : Eye opener

‫ يونت‬2 ‫ او‬1 ‫فهذا طبعا اخطر من الي يشرب باليوم‬ The patient should be given 1 point for each
question they answer yes to , A score of over 2
suggests problematic drinking.
 O/E = On Examination

ABCPMSSSCDD

A : Appearance ( looks ill or comfortable )

B : Body built ( Under – Average – Over Wt. )
C : Color of skin of his face
P : Position ( Sitting on bed – laying flat on bed )
M : Mental Status ( conscious or semi or DLOC )
( Oriented or Confused )
S : Surroundings ‫من تقدم خليها اخر نقطة‬
( Accessories: cannula – Fluid – Drain – Stoma -
Mask-Foley – NG tube – ETC.. )
S : Spot Dx
S : Soft or Distended abdomen ?
C : Clear Chest or not ?
D : Dyspnea – Tachypnea or Not
D : Dehydration or Not
Created By : Rami Firas AlKayal
Medical Student