Patient's complaints

MARWH ALSADH
 ‫‪ ‬من مىت واهت ثؼاين مهنا؟‬
‫‪ ‬مىت ثبدب(صباح ‪,‬مساء ‪)...,‬ومك من اًوكت جس متر(بضع ساػاث او خالل اٍهنار او اٌََي)‬
‫‪ ‬ىي مرافلو ًيا كضؼرٍرت او جض نج او ثؼرق؟‬
‫‪ ‬ىي ختخفي امحلى من هفسو ا(مك جس متر بلك فرته)‪ ......‬او ابس خخدام ػالج‬
‫‪ ‬ىي امحلى مرافلو بظيور حىو وظفح جدلًو‬
‫‪ ‬ىي ٌض خيك من وحو وامل يف اًصدر وامل يف اًبعن وصداع او ىي ًفلد اًوغي ‪,‬وامل يف املفاصي او هلصان يف اًوزن‪....‬‬

‫‪ ‬من مىت بدبث اًىحة‬

‫‪ ‬ىي مس مترت او ػىل صلك هوابث‬
‫‪ ‬ىي اًسؼةل جافو او مرفلو ببَغم ؟ادا يف بَغم وسأل ػىل(اًمكَو‪ ,‬اٌَون‪ ,‬اًراحئة‪ .‬مىت (ابًصباح او املساء)‪.‬ىي يف دم او ال ‪.‬وىي هل‬
‫ػالكو بخغري وضؼَو اجلَوس ؟‬
‫‪ ‬ىي مرافلو مع ضَق هفس وامل ابًصدر‬
‫‪ ‬ىي اًسؼةل حزداد مع اًغبار‪ ,‬اًيواء اًبارد‪ ,‬ادلخان‪......‬‬
‫‪ ‬ىي جتي بؼد اللك بو اًرشة‬
‫‪ ‬مىت حزداد بضده ابًصباح او ابملساء‬
‫‪ ‬وصف ٌَىحة‬
‫‪ ‬ىي جس خخدم ػالج ًيا‬
‫‪ ‬ىي اهت مرًض مثي امراض (اًلَب‪ ,‬اًلكى ‪,‬بزمو)‪.‬‬

‫‪ ‬اٍن ماكن الامل؟ مىت بدب جفاءه او ثدرجيَا؟‬

‫‪ ‬اوصف يل الامل ؟‬
‫‪ ‬ىي ٌسمع الامل ملاكن اخر‬
 ‫‪ ‬اٌش الاغراض املرافلة ًلمل(حىو ابجلدل ‪,‬ثؼرق ‪,‬غثَان‪)...‬‬
‫‪ ‬مك مده الامل؟ ومك كل واهت ثخأمل؟‪ ,‬مىت جيي كل؟‬

‫‪ ‬اٌش ايل ٍزًد الامل و اٌش ايل خيففو‪.‬؟‬

‫(هفس الس ئةل اًسابلة وهضَف ىي مرافق ًيدا بلمل (اسيال ‪,‬ءيء‪ ,‬صؼوبة ابًيضم ‪,‬اهخفاخ ابًبعن‪ ,‬مضالك بوًَو‪)...‬‬

‫‪ ‬الامل ابملرنز او بنلعو حمدده؟ هَف بدا الامل جفاءه او ثدرجيي؟‬

‫‪ ‬ظبَؼة الامل (حاد‪ ,‬متزق‪ ,‬ظؼن‪ ,‬ضاغط ػىل اًصدر‪)....‬‬
‫‪ ‬ىي ٌسمع الامل ملاكن اخر؟ مك ٌس متر الامل‬
‫‪ ‬اٌش ايل ٌسبب كل الامل و اٌش ايل ٍزًده‬
‫‪ ‬وايل هيدئ او خيففو‬
‫‪ ‬ىي ٍرافق ىدا الامل اغراض اخرى‬

‫‪ ‬ىي بدئت جفاءه او ثدرجيي‬

‫‪ ‬ىي جتي كل بؼد جميود او يف حاهل اًراحة اًضا؟؟‬
‫(ادا املرًض حدد بؼد اجمليود وس ئي هوع اجمليود ايل ٌسوًو مثال امليش ظَوع درج ‪,‬ىي ًلدر ًغري مالبسو من غري ما حيس بضَق هفس)‬

‫‪ PND ‬ىي ثلوم ابٌََي جفاءه جض يت ثدنفس وهَف جسوي غضان حراتح‬
‫‪ ‬ىي ملا حمتدد ػىل اًفراش ًنلعع هفسم ؟‪,‬ومك جس خخدم خمداث ؟‪.‬‬
‫‪ ‬ىي جضؼر اهو (ضَق اًخنفس) ٍزداد مع الاايم او خيف‪.‬‬
‫‪ ‬ىي مذؼَق بأايم احلر او اايم اًربد‬
‫‪ ‬ىي سافرث خارج اًبدل‬
‫‪ ‬ىي ثدخن ؟ادا كال هؼم مك جسائر ابًَوم؟‬
 ‫‪ ‬ىي يف غوامي حزًدىا مثال ادا ثؼرضت ًغبار او اي ماده مؼَنو مثال اًسََاك (ماده ثصنع ًزجاج) ىي ٍزًد ضَق اًخنفس‬
‫‪ ‬ىي حرافق اغراض اخرى مثي امل ابًصدر ‪,‬وحو‪ ,‬صوث صفري ‪,‬وحو مع دم‪.‬‬
‫‪ ‬ىي غندك مضلكو من كبي مثي امراض كَب او حساس َو؟‬

‫‪ ‬من مىت واهت ثخلئ‬

‫‪ ‬مك مراث ثخلئ ابًَوم؟ اٌش حمخوايث اًليء؟‬
‫‪ ‬ىي اًليء دم او ال‬
‫‪ ‬اٌش ًون اًليء؟ ىي اًليء مصاحب ابًغثَان؟‬
‫‪ ‬ىي اًليء ٍىون ابًصباح فلط‬
‫‪ ‬ىي جضؼر ملن جض يت ثخليء‬
‫‪ ‬ىي اًليء ٍىون ٍىون ملسافو بؼَده‬
‫‪ ‬ىي ملن ثخليء حراتح والمل ايل يف بعنم ٍزول‬
‫‪ ‬ىي اًليء هل ػالكو ابللك‬
‫‪ ‬ىي حصي ورضبت ربسم‬
‫‪ ‬ىي ثأخذ ػالج‬
‫‪ ‬ىي اًليء مصاحب )‪)fever ,vertigo ,tinnitus ,jaundice ,diarrhea ,weight loss, headache ,chest pain‬‬
‫‪ ‬وسأل ادا ىو مصاة ابي مرض مثي (‪)hepatic ,renal, migraine ,carcinoma‬‬
 ‫‪ ‬ىي بدبث مع فلدان صيَو غثَان او ءيء‬
‫‪ ‬ىي ثواصَت من كبي مع ‪jaundiced patient‬‬
‫‪ ‬ما ًون اًرباز‬
‫‪ ‬ىي يف حىو‬
‫‪ ‬ىي اخدث حلن ؟ او هلَت دم‬
‫‪ ‬ىي اخدث ادوًو ‪ I.V‬و معَت معََو‬
‫‪ ‬ىي احد من ػائَخم مصاة هفسم‬
‫‪ ‬ىي ىده اًصفارت جتي وحروح‬
‫‪ ‬ىي مصاحبو ة ‪fever or urinary complaints‬‬
‫‪ ‬ىي سافرث؟‬
‫‪previous history of jaundice? ‬‬

‫‪ ‬وٍن ماكن اًصداع‪)frontal ,occipital ,unilateral or diffuse(:‬‬

‫‪ ‬مىت جيي كل اًصداع ؟ وهَف صده الامل؟‬
‫‪ ‬اوصف يل اًصداع ؟ وهَف بدب؟ ومك جيَس‬
‫‪ ‬ىي جيي وخيف؟‬
‫‪ ‬ىي يف اص َاء حزًده مثي اًىحة اًوكوف او ملن ثغري وضؼَخم‬
‫‪ ‬اٌش ثؼمي من اجي ختففو؟‬
‫‪ ‬ىي يف ‪aura‬‬
‫‪ ‬ىي مرافق ٌَصداع )‪)fever , vomiting ,weakness, vertigo, nasal stuffiness ,breathlessness ,blurring of vision‬‬
‫‪ ‬جرشة ػالج ؟ وىي زرث منعلو موبوءت‬
 ‫ ىي الامل حاد او ثدرجيي ٍزداد او مزمن‬
‫ ىي الامل جدًد او مذىرر‬
trauma ‫ وسأل غن اترخي‬
‫ مك مده مؼاانثو من الام املفاصي؟ ىي ًرتافق مع ثورم املفاصي‬
)mono ,oligo, or polyarthritis(‫ ػدد املفاصي ايل ٌض خيك من امليا‬
 Distribution of joint involvement (small or large joint involvement(
 Upper or lower limb or both involvements.
 Does the pain move from one joint to other? (migratory or fleeting, additive(
 Does the pain worsen on activity or rest‫؟‬
 Is there any morning stiffness? If present, how long does it persist? How does it
subside? (improve with activity or exercise)
 Is it associated with redness, warmth and swelling? (suggest
inflammation)
 Is there any deformity?
 Is there any extra-articular manifestation?
 Is this associated with dry mouth? (Sjogren syndrome)
 Do you have any skin or nail problem or is there any family history of
such problem? (psoriatic
 arthritis)
 Is there any history of persistent bleeding?
 Is the arthritis preceded by urethritis, history of sexual contact, acute
diarrhea (Reiter’s syndrome, also may be eye problem)?
 Is there any history of frequent diarrhea? (IBD)
Is there any history of tick bite in endemic area? (Lyme disease)

DYSPHAGIA
 Can you show me with your finger at which level does the food get
stuck?
 Is it due to solid or liquid or both?
 Is it painful or painless?
 Is it transient, intermittent or progressive?
 Do you have nasal regurgitation or cough during deglutition?
 Is it associated you heart burn or chest discomfort?
 Is there any difficulty to swallow?
 Did you notice bulging of the neck while eating or drinking?

 Is it generalized or localized?
 Distribution: is it proximal or distal?
 Onset: is it sudden or gradual?
 Progression: Is it ascending or descending?
 Does it worsen or improve with activity?
 Is there other features, such as muscle pain, skin rash, sensory loss, loss
of bowel or bladder control?
 Do you take any drug ?

 How much weight did you lose? Over what period?

 How is your appetite?
 How is your bowel habit? (If frequent diarrhea or loose motion, ask
details regarding color, amount, presence of blood, etc.).
 Do you feel excessively thirsty and micturate frequently?
 Do you have other symptoms, such as cough, fever, night sweat?
 Do you have palpitation?
 Do you prefer hot or cold environment?
 Do you feel that you are getting darker than before? (any change in
your complexion?)
 Do you have vomiting? If yes, is it spontaneous or induced?
  How much weight did you gain? Over what period?
 How is your appetite?
 Do you feel weak or fatigue?
 How is your bowel habit?
 Do you prefer hot or cold environment?
 Do you take any drugs ?
 How is your menstrual cycle? Any growth of excessive hair? (For
female).
Do you have headache?

 Onset—is it sudden or gradual?

 Is it recurrent, persistent or progressively increasing?
 If recurrent, what is the frequency and duration?
 Do you feel that the surrounding is moving or do you feel yourself to
be moving?
 What causes the vertigo? (movement of the head, standing from sitting
position, traveling in a motor vehicle ,anxiety ,stress, menstruation,
etc.).
 Does it relate to change in head posture?
 How severe is it?
 Did you ever suffer any head injury or trauma to the head?
 Is it associated with symptoms, such as hearing loss, tinnitus,
headache, nausea, vomiting, pallor,
 sweating, double vision, frequent fall, ataxia, focal weakness,
confusion or loss of taste sensation?
 Do you take any drugs? (aminoglycoside)
.
SWELLING OF THE BODY

 Is it generalized, involving the whole body or localized to a part?

 If generalized, where did it first appear? (Face, feet, abdomen).
 If localized, is the swelling painful?
 What is the amount of urine you pass every day? Is there any pain or
burning?
 What is the color of your urine?
 Do you feel palpitation, cough, chest pain or breathlessness on exertion?
 Any history of sore throat or skin infection?
 Do you have diabetes mellitus or hypertension?
 Do you have cold intolerance, constipation, lethargy?
 Do you take any drugs? (steroid, amlodipine, nifedipine).
How is your bowel habit ?

 What is the amount of water you take and void every day?
 Are you suffering from diabetes mellitus?
 Is it associated with excessive thirst?
 Do you have excessive thirst with polyphagia?
 Are you taking any drugs? (diuretic, lithium, analgesic, cidofovir,
foscarnet)
 Do you take excessive coffee?
 Do you have excess thirst, abdominal pain, constipation, etc.?
 Do you have history of head trauma, pituitary surgery or stroke?
(Take history of psychiatric illness).


 Is it at the beginning of micturition or at the end or throughout? (initial,
terminal or total)
 Do you feel pain or burning during micturition? (dysuria)
 Is this associated with frequency, urgency or hesitancy?
 Do you have loin pain? Does it radiate to the groin? Do you have pain in
lower abdomen or generalized abdominal pain? (If the patient complains
of any pain, take detailed history as given in page …).
 Have you noticed bleeding from any other part of the body?
 Do you have fever? (If yes, take detailed history of fever).
 Is it associated with nausea or vomiting?
 Have you noticed any rash? Is it associated with joint pain and swelling?
 Do you take any drugs? (anticoagulant, antiplatelet, analgesic,
cyclophosphamide, antibiotic).
 Did you ever pass stones previously?
 Did you suffer from any kind of trauma?
 Did you suffer from skin infection or sore throat recently?
 Do you have hypertension, exertional breathlessness and swelling of the
body?
 Is there any history of renal disease in your family?
 In female, enquire whether she is menstruating.
 Take occupational history specially looking for exposure to radiation or
industrial chemicals like benzene..
Have you recently traveled to any Middle Eastern country (to exclude
bilharziasis or schistosomiasis)?