HISTORY

This is a 45 year-old male, presented to the ER with a history of chest pain, 2 hours ago, take a relevant history. Profile Chief complaint and duration (chest pain, remained for how long?) HPI (analysis for chief complaint SOCRATES, A: Cardiac symptoms (SOB/orthopnea/PNDs, pain, edema, palpitations, intermittent claudication, and syncope). General symptoms (headache, sweating, nausea). Other suspected systems (cough, wheezes). Relation to position and respiration. Conditions before pain (food, exercise, cold) what was he doing? First attack or not? Activity, exercise tolerance) Past history (HTN, DM, ACS, catheterizations, ask if HTN and DM are controlled or not) Drugs and allergies (what drugs has he taken, allergies to foods or drugs) Family history (of HTN, DM, controlled, ACS) Social history (smoking and alcohol)

This is a 33 year-old male, presented with hemoptysis, take a relevant history, then give your diagnosis. Profile (mentioned) Chief complaint and duration (duration: 3 months) HPI (analysis of chief complaint: smoking (how many packs/day, for how many years) onset, timing, exacerbating/relieving factors, associated symptoms (cough (day/night variation, timing, relation to food and to hemoptysis), sputum (amount and color), shortness of breath, fever (day/night variation, documented), weight loss, appetite, night sweats, masses, contact to sick people. Bleeding from other sites. First attack or not) Past history (past illnesses) Drugs and allergies Family history of same condition Social history (where does he live, contact to animals)

21 year-old female, presented with epigastric pain for the last 6 months, take a relevant history. Profile (mentioned) Chief complaint and duration (mentioned) HPI (analysis of pain SOCRATES, A: nausea, vomiting, heartburn, sweating, diarrhea/constipation and normal bowel habit, melena, pain awakens from sleep, Page 1

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dysphagia, regurgitation, fever, distension, weight loss, appetite, masses. Relation to food and drinks (time and type), to menses, to stress) Past history Drugs and allergies Social history (smoking and alcohol)

24 year-old female, claiming that she lost 6 kgs (from 62 to 56) though shes not on diet, take a relevant history. Profile (mentioned) Chief complaint and duration (mentioned) HPI (analysis of chief complaint: appetite, early satiety, type of food and drinks, number of meals, lifestyle, work, exercise, activity, abdominal/epigastric pains, vomiting and nausea, diarrhea/constipation, sweats/night sweats, tremor, fatigability, nervousness, heat intolerance, palpitations, oligomenorrhea, neck masses, happy about her weight) Past history (radiation, pregnancy) Drugs and allergies Family history (of thyroid disease) Social history (smoking)

67 year-old male, complaining of shortness of breath for the last 2 weeks, take relevant history. Profile Chief complaint and duration HPI (analysis: onset (sudden vs slow), timing, pain (pleuritic/central, relation to breathing, exercise, position), cough and sputum analysis, fever, orthopnea/PNDs, edema in abdomen or lower limbs, activity, exercise, intermittent claudication. Other causes of effusion: low protein, loss of appetite and weight, anemia (fatigability), smoking) Past history (HTN, DM, ACS, asthma and COPD) Drugs and allergies Family Social

30 year-old male, complaining of lower limb swelling for the last month, take a relevant history. Profile Chief complaint and duration HPI (analysis: unilateral/bilateral, onset (sudden vs progressive) timing (on and off), painful/painless, borders (below knee, above knee), activity, exercise, shortness of Page 2

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breath, hemoptysis, fever, sleeping, low protein: proteinuria, other urinary symptoms: frequency, urgency, hesitancy, incontinence, color, smell and appearance of urine) Past history (HTN, DM -> the patient has DM type I and HTN, ask about control -> eyes, hands and feet, etc) Drugs and allergies (hes on insulin and antihypertensive) Family Social (smoking, occupation -> hes a teacher, stands most of the time)

60 year-old patient complaining of chronic cough for the last 3 years, take a relevant history. Profile Chief complaint and duration HPI (analysis: onset, progression, timing, day/night variation awakes him from sleep, sputum amount and color, fever, shortness of breath, weight loss, appetite, smoking, hemoptysis, chest pain and relation to breathing and sleeping, exercise tolerance, activity. Past history (DM, HTN, asthma or COPD (he doesnt know if he has asthma or COPD), ask about previous admissions because of same problem, personal history of asthma or atopy (allergic rhinitis, conjunctivitis, eczema)) Family history (asthma or atopy) Social (smoking, contact with animals)

20 year-old female, complaining of bloating for the last 5 years, her Hb was 7.4, MCV 65. Take a relevant history. Profile Chief complaint and duration HPI (analysis: onset, progression, timing, relation to food and drinks, details about food intake, number of meals, type of foods, abdominal pain analysis, appetite, weight gain, nausea and vomiting, diarrhea/constipation analysis, amount, color, flushing. Flatulance. Then ask about symptoms of anemia: SOB, fatigue, dizziness, chest pain, bleeding, menses) Past history Drugs and allergies Family history (of same condition) Social

32 year-old male, complaining of diarrhea for the last 3 months. Take a relevant history. Profile Page 3

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Chief complaint and duration HPI (analysis: deviation of normal bowel habit regarding frequency, consistency and amount, detailed analysis of defecation: tinismus, abdominal pain, urgency to defecate, color of stool, consistency, easily flushed or not, presence of mucus or blood or melena, feeling of mass during defecation, pain relieved by defecation or not, appetite, weight, nausea, vomiting, distention, analysis of pain, awakens from sleep. Extraintestinal manifestations: eye pain, blurred vision, joint pains, skin manifestations or discolorations, palpable masses) Past history (previous admissions) Drugs and allergies Family history (of same condition) Social (smoking and alcohol)

Other questions: - History of melena (Peptic ulcer) - Joint pain (Rheumatoid arthritis, look criteria for RA) - Fever of unknown origin (brucellosis) Notes: - Diarrhea and constipation refers to change in frequency, consistency, or amount of stool (normal bowel habit: three times/day to once/three days) - When theres a joint pain, ask about eye symptoms and diarrhea. And when theres diarrhea ask about joint pain and eye symptoms. - Always start with analyzing chief complaint, then symptoms of most suspected system, then general symptoms. - Analyze each symptom and its relation to the chief complain (if the patient chiefly complaining of pain and has vomiting, analyze vomiting (amount, frequency, color) and its relation to pain (did it happen before pain or after? Did it relieve you pain?)

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