Download MedicalRecord

Outline of Medical History Record
I.
Identification
a) Patient’s name
b) Sex
c) Residence
d) Birth of date and age
e) Source of referral
II.
Informant
a) The sources of the history
b) Interpreters
III.
Chief Complaints (CC): a list of one or more symptoms that caused the patient to seek
attention
a) Name of complaints
b) Approximate duration in time units
IV.
History of Present Illness (HPI)
a) Symptoms (clarification, quantification, chronology, current activity, and
summarization)
i.
Provocative or Palliative maneuvers
ii.
Quality of the symptom
iii.
Region involved
iv.
Severity
v.
Temporal pattern of the symptom
b) Search for Diagnostic Clues
V.
Past Medical and Surgical History (PH)
a) General health
b) Chronic and episodic illnesses
i.
Chronic medical illness (e.g. obesity, diabetes, hypertension, gout, rheumatoid
arthritis, cancer, psychiatric illnesses, seizure disorders, and sleep disorders)
ii.
Infectious diseases (e.g. measles, German measles, mumps, whooping cough,
chickenpox, smallpox, diphtheria, typhoid fever, malaria, hepatitis, scarlet fever,
rheumatic fever, chorea, pneumonia, tuberculosis, sexually transmitted diseases,
and HIV)
1. List dates and complications
2. Give dates of chemotherapy and antibiotic treatment
3. Reactions to antibiotics under “allergies and medication intolerances”
c) Operations and injuries (give dates and nature of injuries, operations, operative
diagnoses, and infection, hemorrhage or other complications)
d) Previous hospitalizations
i.
Dates and names of hospitals and their locations.
ii.
Summary of the dates and diagnoses for each admission if applicable.
VI.
Family History (FH)
a) Four generations: grandparents, parents, aunts and uncles, siblings, and children
b) Keep notes of: hypertension, heart disease, diabetes, kidney disease, autoimmune
diseases, gout, atopy, asthma, obesity, endocrine disorders, osteoporosis, cancer
(particularly breast, colon, ovarian and endocrine cancers), hemophilia or other bleeding
diseases, venous thromboembolism, stroke, migraine, neurologic or muscular disorders,
mental or emotional disturbances, substance abuse, and epilepsy.
VII.
Social History (SH)
a) Place of birth
b) Nationality and ethnicity (geography, history, and anthropology)
c) Marital status (single, married, divorced, or widowed; duration and explanation of
termination)
d) Occupations (work history, education, social status, physical exertion, psychologic
trauma, exposure to agents, and other conditions that may cause disease)
e) Military history (admissions to the armed services, branch of service, geographic
locations of the service, discharge – honorable or dishonorable, eligibility for veteran’s
benefits)
f) Gender preference (heterosexual, homosexual, and bi-sexual)
g) Social and economic status (years of formal education, vocational training, current
housing type, living arrangements, and any special financial problems)
h) Habits (use of tobacco, coffee, alcohol, sedatives, illicit drugs – especially any injection
drug use, placement of tattoos, and body piercing)
i) Violence and safety (use of vehicle restraints, helmets, and presence of smoke and
carbon monoxide alarms in the home)
j) Prostheses and in-home assistance (use of eye-glasses, dentures and dental appliances,
hearing aides, ambulation assistance devices – cane/walker/scooter/wheelchair, braces,
prosthetic footwear, and any assistance received in the home – visiting nurse/physical
therapy/homemaker service)
VIII. Review of Systems (ROS)
a) Integument
i.
Skin: color, pigmentation, temperature, moisture, eruptions, pruritus, scaling,
bruising, bleeding.
ii.
Hair: color, texture, abnormal loss/growth, distribution
iii.
Nails: color changes, brittleness, ridging, pitting, curvature
b) Lymph nodes: enlargement, pain, suppuration, draining sinuses, location
c) Bones, joints, and muscles: fractures, dislocations, sprains, arthritis, syositis, pain,
swelling, stiffness, migratory distribution, degree of disability, muscular weakness,
wasting, or atrophy, night cramps.
d) Hemopoietic system: anemia – type/therapy/response, lymphadenopathy, bleeding or
clotting – spontaneous/traumatic/familial
e) Endocrine system
i.
History of growth, body configuration, and weight
ii.
Size of hands, feet, and head, especially changes during adulthood
iii.
Hair distribution
iv.
Skin pigmentation
v.
Goiter, exophthalmos, dryness of skin and hair, intolerance to heat or cold, tremor
vi.
Polyphagia, polydipsia, glycosuria
vii.
Secondary sex characteristics, impotence, sterility, treatment
f) Allergic and immunologic history
i.
Dermatitis, urticaria, angioedema, eczema, hay fever, vasomotor rhinitis, asthma,
migraine, vernal conjunctivitis and seasonal occurrence of these
ii.
Known sensitivity to pollens, foods, danders, x-ray contrast agents, bee stings
iii.
Previous skin tests and their results
iv.
Results of tuberculin tests and others
v.
Desensitization, serum injections, vaccinations, and immunizations
g) Head: headaches, migraine, trauma, vertigo, syncope, convulsive seizures
h) Eyes: loss of vision or color blindness, diplopia, hemianopsia, trauma, inflammation,
glasses (date of refraction), discharge, excessive tearing
i) Ears: deafness, tinnitus, vertigo, discharge from the ears, pain, mastoiditis, operations
j) Nose: coryza, rhinitis, sinusitis, discharge, obstruction, epistaxis
k) Mouth: sourness of the mouth or tongue, symptoms referable to teeth
l) Throat: hoarseness, sore throats, tonsillitis, voice changes
m) Neck: swelling, suppurative lesions, enlargement of lymph nodes, goiter, stiffness, and
limitation of motion
n) Breasts: development, lactation, trauma, lumps, pains, discharge from nipples,
gynecomastia, change in nipples.
o) Respiratory system: pain, shortness of breath, wheezing, dyspnea, nocturnal dyspnea,
orthopnea, cough, sputum, hemoptysis, night sweats, fevers, pleurisy, bronchitis,
tuberculosis – history of contacts, pneumonia, asthma, other respiratory infections
p) Cardiovascular system
i.
Palpitation, tachycardia, irregularities or rhythm, pain in the chest, exertional
dyspnea, paroxysmal nocturnal dyspnea, orthopnea, cough, cyanosis, ascites,
edema
ii.
Intermittent claudication, cold extremities, thromboses, postural or permanent
changes in skin color
iii.
Hypertension, rheumatic fever, chorea, syphilis, diphtheria
iv.
Drugs such as digitalis, quinidine, nitroglycerin, diuretics, anticoagulants,
antiplatelet agents, and other medications
q) Gastrointestinal system: appetite, changes in weight, dysphagia, nausea, eructation,
flatulence, abdominal pain or colic, vomiting, hematemesis, jaundice (pain, fever,
intensity, duration, color of urine and stools), stools (color, frequency, incontinences,
consistency, odor, gas, cathartics), hemorrhoids, change in bowel habits
r) Genitourinary system
i.
Color of urine, polyuria, oliguria, nocturia, dysuria, hematuria, pyuria, urinary
retention, urinary frequency, incontinence, pain or colic, passage of stones or
gravel.
ii.
Gynecologic History: Age of onset, frequency of periods, regularity, duration,
amount of flow, leukorrhea, dysmenorrhea, date of last normal and preceding
periods, date and character of menopause, postmenopausal bleeding; pregnancies
(number, abortions, miscarriages, stillbirths, chronologic sequence), complications
of pregnancy; birth control practices (oral contraceptive medications, barrier
methods, etc.).
iii.
Male History: Erectile dysfunction, premature ejaculation, blood in the semen,
contraceptive methods and condom use.
iv.
Venereal Disease History: Sexual activity (sex of partners and practices), chancre,
bubo, urethral discharge, treatment of venereal diseases.
s) Nervous system
i.
Cranial Nerves: Disturbances of smell (cranial nerve I), visual disturbances (CN II,
III, IV, VI); orofacial paresthesias and difficulty in chewing (CN V); facial
weakness and taste disturbances (CN VII); disturbances in hearing and equilibrium
(CN VIII); difficulties in speech, swallowing, and taste (CN IX, X, XII); limitation
in motion of neck (CN XII).
ii.
Motor System: Paralyses, atrophy, involuntary movements, convulsions, gait,
incoordination.
iii.
Sensory System: Pain, lightning pain, girdle pain, paresthesia, hypesthesia,
anesthesia, allodynia.
iv.
Autonomic System: Control of urination and defecation, sweating, erythema,
cyanosis, pallor, reaction to heat and cold.
t) Psychiatric history: Describe difficulties with interpersonal relationships (with parents,
siblings, spouse, children, friends and associates), sexual adjustments, employment
success and difficulties, impulse control, sleep disorders, mood swings, difficulty with
concentration, thought or the presence of hallucinations.
IX.
Medications: names, doses, effects, reason of taking, and duration
X.
Allergies and Medication Intolerances
XI.
Preventive Care Services: dates and results of screening tests, insurance examinations,
and immunizations.
XII.
Advance Directives
XIII. Physical Examination (PE)
a) Vital signs
b) General appearance
c) Head, eyes, ears, nose, and throat (HEENT)
d) Neck and spine
e) Chest: breasts
f) Chest: chest wall and lungs
g) Chest: heart, major arteries, and neck veins
h) Abdomen
i) Genitourinary exam, including inguinal hernias
j) Rectal exam
k) Extremities
l) Lymph nodes
m) Neurologic exam, including the mental status exam
n) Skin
XIV. Laboratory and Imaging Studies
XV.
Assessment
XVI. Plan
DeGowin, Richard L.; LeBlond, Richard F.; Brown, Donald D.. DeGowin's Diagnostic
Examination.
New York, New York, USA: McGraw-Hill, 2004. p 85.
http://site.ebrary.com/lib/princeton/Doc?id=10176682&ppg=85
Copyright © 2004. McGraw-Hill. All rights reserved.