History

History

DEMOGRAPHICS: Name/Age/DOB/Gender/Ethnic heritage/Marital status/Religious preference/Place of birth/Date of admission or clinic visit/Date of examining Pt/

SOURCE and RELIABILITY: Include id of person providing hx; relationship of the source to pt; if old records were used; assess reliability of the person(s) providing the data.

CC: include reason for presenting to clinic or hospital, in Pt's. own words if possible, and duration; Why now? If no c/o, specify goal or reason for visit.

HPI:

  • p1- include summary of CC and introduce immediately relevant PMH. Note If the problem happened before?

  • p2- chronologically record onset of illness, setting in which it occurred, its manifestations (CHLORIDE PP), other sx assoc. c CC., any Labs done, and any treatment obtained - results of Tx. If the problem has happened before and is been active since, or on & off sx.

  • p3- pertinent +/- ve sx/systems related to the developing hypothesis (CC and DDX) or systems in which the sx fall.

  • p4- Up-to-date data since Pt's admission ER, MICU. PE, Labs, Tx, until now. If Pt. had surgery, (postop fevers) W, W, W, W, and W. Note any change in sx from the pre-op to now.

  • Sx since floor admit - f/u sx from p2, PE findings, tx to date.

CURRENT HEALTH STATUS

  • Meds: name/dose/route/frequency/class/use of each

  • Allergies: allergen/reaction

  • PMHx

  • Adult illnesses: name, date, Tx, complications

  • Childhood illnesses: same

  • Immunizations: (+) name, date or (-) name

  • Pertinent illnesses denied: (-) DM, MI, CA

  • Previous admission:

  • Surgeries: name, date, complications

  • OB/GYN Hx: menarche, menstural interval duration, flow, presence of cramps, LMP, IMB, PCB, BCP, PMS, perimenopausal sx, VB, VD, Hyg, BCP, HRT, sex, risk behavior.

  • OBHx: date, term, sex, wt, NSVD/C-section (type), where, who, outcome.

Fam. Hx: pedigree chart (4 gen, if possible). Occurrence or absence of any of the following conditions:

  • DM/ HTN/ Heart disease/migraine/ stroke/ kidney disease/ PUD/ cancer/ thyroid problems/ TB/anemia/ seizures-epilepsy/ arthritis/ autoimmune disease/ depression/ mental disease/ alcoholism/ recreational drug use/ obesity/ allergy/ asthma/ high cholesterol/ gout/ bleeding disorders/ unexplained sudden death/ genetic disorders/ disorders or symptoms like those of the patient

SHx:

  • Tobacco use pk/yrs; rec. drugs type/amt/freq/last use; ETOH type/amt/freq/last use; env. hazards, use of safety devices, home situation and significant others; social support systems); ADLs and IADLs, diet, caffeine, sleep pattern, level of education, emp. hx, sexual activity, risk behavior profile, exercise and leisure activities, travel, impact of illness on the patient's life-as a person, worker, spouse, and parent.

ROS: CHLORIDE PP all positives. Negative unless otherwise noted.

  • GENERAL: changes in wt, apetite. Fever, chills, night sweats, weakness, fatigue.

  • SKIN: rashes, lesions, discoloration, lumps, moles, dry skin, changes in hair and nail changes.

  • HEENT: HA, head injury, dizziness, and lumps. Last eye exam, glasses, blurring, diplopia, floaters, photophobia, halos around lights. Change in hearing, tinnitus, vertigo, otalgia, otorrhea, wax, FB. Colds, nasal d/c, epistaxis, obstruction, FB, sinusitis, sinus pain. Last dental exam, dental hygiene, dentures, sorethroat, hoarseness, soretongue, bleeding gums, impaired taste, bad breath.

  • NECK: lumps, goiter, neck stiffness, neck tenderness,

  • BREAST: lumps, d/c, pain, tenderness, mammogram.

  • RS: cough/sputum, wheezing, hemoptysis, pleuritic CP, SOB, TB-skin test, CXR, PFTs.

  • CVS: CP, SOB (NYHA functional class), orthopnea, PND, palpitation, dizziness, diaphoresis, pedal edema, BP, HPL, last ECG.

  • GI: dysphagia, odynophagia, N/V/C/D, heartburn, abdominal pain, altered bowel routine, hematemesis, melena, hematochezia, rectal bleeding, hemorrhoids, food intolerance, jaundice, gall bladder dz, flex-sig, c-scope.

  • GU: dyuria, hematuria, nocturia, freq., urgency, difficulty in starting stream, hesitancy, nephrolithiasis, flank pain, groin to loin pain.

  • Male: lesions on penis, DC, impotence, pain, freq., of intercourse, condom use, testicular pain.

  • Female: lesions on external genitalia, itching, DC, dyspareunia, ask for BCP.

  • MSS: joint pain or swelling, stiffness, backache, or neck pain.

  • NEURO: Fainting, dizziness, syncope, "black outs,"seizures, paresthesiae, paralysis, tremors, dysarthria, aphasia, apraxia, gait d/o, MS changes, bowel and bladder incontinence.

  • PSY: Memory, nervousness, stress, mood changes, hallucinations, anxiety, depression, SI/HI.

  • ENDO: Thyroid disorder, heat or cold intolerance, excessive sweating, polyuria, polydipsia, polyphagia.

  • PV: DVTs, varicose veins, swelling of legs, claudication, coolness of extermity, loss of hair on legs, discoloration of extremity, dystrophic nails, ulcers on extremities.

  • HEMAT: Anemia, easy bruising, bleeding, prior blood transfusions and reactions.