History Taking
Insert:
History of presenting history order 1. **Chief Complaint:**
- The patient's primary reason for seeking medical attention.
- Stated in the patient's own words, using quotation marks.
- Should be concise and descriptive.
2. **History of Present Illness (HPI):**
- Detailed description of the chief complaint, including:
- Onset: When did the symptoms start?
- Duration: How long have the symptoms been present?
- Location: Where are the symptoms located?
- Quality: What do the symptoms feel like?
- Severity: How severe are the symptoms?
- Associated symptoms: Any other symptoms that are related to the chief complaint?
- Aggravating factors: What makes the symptoms worse?
- Relieving factors: What makes the symptoms better?
3. **Past Medical History (PMH):**
- A chronological list of all medical conditions that the patient has ever had, including:
- Diseases: Any diseases that the patient has been diagnosed with.
- Surgeries: Any surgeries that the patient has undergone.
- Injuries: Any injuries that the patient has sustained.
- Hospitalizations: Any hospitalizations that the patient has had.
4. **Current Medications:**
- A list of all medications that the patient is currently taking, including:
- Name of the medication
- Dosage
- Frequency
- Route of administration
- Reason for taking the medication
5. **Allergies:**
- A list of all allergies that the patient has, including:
- Name of the allergen
- Type of reaction (e.g., rash, hives, swelling)
- Severity of the reaction
6. **Social History:**
- Information about the patient's lifestyle, including:
- Occupation: What does the patient do for a living?
- Education: What is the patient's highest level of education?
- Marital status: Is the patient single, married, divorced, or widowed?
- Family structure: Who does the patient live with?
- Substance use: Does the patient use any tobacco, alcohol, or drugs?
- Sexual history: Any sexually transmitted infections (STIs) or high-risk sexual behaviors?
7. **Family History:**
- A list of the patient's family members and their medical conditions, including:
- Parents: Any diseases, surgeries, or injuries that the patient's parents have had.
- Siblings: Any diseases, surgeries, or injuries that the patient's siblings have had.
- Children: Any diseases, surgeries, or injuries that the patient's children have had.
8. **Review of Systems (ROS):**
- A systematic review of all the body systems, asking the patient about any symptoms that
they have experienced, including:
- General: Any fatigue, weight loss, or fever?
- Skin: Any rashes, lesions, or itching?
- Head and Neck: Any headaches, dizziness, or vision problems?
- Eyes: Any pain, redness, or discharge?
- Ears: Any pain, hearing loss, or tinnitus?
- Nose: Any congestion, runny nose, or nosebleeds?
- Throat: Any sore throat, hoarseness, or difficulty swallowing?
- Respiratory: Any cough, shortness of breath, or chest pain?
- Cardiovascular: Any chest pain, palpitations, or shortness of breath?
- Gastrointestinal: Any abdominal pain, nausea, vomiting, or diarrhea?
- Genitourinary: Any urinary frequency or urgency, dysuria, or hematuria?
- Musculoskeletal: Any joint pain, swelling, or stiffness?
- Neurological: Any headaches, seizures, or weakness?
- Psychiatric: Any depression, anxiety, or mood changes?
- Endocrine: Any thyroid problems, diabetes, or weight changes?
