THE MEDICAL HISTORY 1.

Summarize briefly
General Data 2. Check accuracy
Chief Complaint/Reason for Seeking Care 3. Check if the patient is ready for the next step.
History of Present Illness (HPI)
Past Health History (PHH) Step 5: Transition to the Doctor-Centered Process (30
Family History (FH) seconds)
Personal and Social History (PSH) The interviewer uses this step to close the patient
Menstrual and Obstetrical History centered portion of the interview and open the doctor-
Review of Systems (ROS) centered process to obtain the details needed to
complete the patient's history.
Introduce yourself. 1. Summarize briefly
 Never forget patient names This summary should not be more than 2 or 3
 Greet patient appropriately in a friendly relaxed way sentences,
 Confidentiality and respect patient privacy "So you have a bad headache with nausea that is
aggravated by your concerns about increased
responsibility at work and at home."
THE PROCESS 2. Check accuracy "Is that the gist of it?"
STEP 1: SETTING THE STAGE FOR THE INTERVIEW 3. Indicate that both content and style "Is it okay if I
1. Welcome the patient shift gears and ask some more specific questions about
2. Use the patient's name your of inquiry will change if the patient headache?" If
3. Introduce yourself and identity. this is not done, the controlling style of the doctor
4. Ensure patient readiness centered is ready process may confuse the patient.
5. Remove barriers to communication
6. Ensure comfort

STEP 2: OBTAINING THE AGENDA INCLUDING THE CHIEF

COMPLAINT
1. Indicate time available.
2. Indicate interviewer's needs
3. Obtain a list of all issues
4. Summarize and finalize the agenda

STEP 3: OPENING THE HISTORY OF PRESENT ILLNESS

1. Use an open-ended beginning question
2. Use nonfocusing open-ended skills.
3. Obtain additional data from nonverbal

STEP 4: CONTINUING THE PATIENT-CENTERED HPI

1. Use focusing open-ended skills to obtain a description
of the physical symptom
2. Use focusing open-ended skills to develop a broader
personal and psychosocial context of a patient's history.
3. Use emotion-seeking skills to develop an emotional
context.
4. Use emotion-handling skills to address elicited
emotions.

STEP 5: TRANSITION TO THE DOCTORCENTERED

PROCESS
PATIENT’S PROFILE Date and Time: History taken by:
Name: No. of times admitted to hospital: Name of hospital/Source of referral:
Sex: Civil Status: Religion: Nationality:
Residence: Occupation: Educational Attainment:
Birthplace: Date of Birth: Age:
Date of Current Admission: Source of Data: Percentage Reliability:

POINTS TO REMEMBER IN TAKING THE HPI

-Start the patient’s narrative by saying: "Tell me about your problem from the very beginning up to the time you were
admitted to the hospital."

-Elicit further information: "Anything else?"

-The questions should be phrased properly so that the patient provides the information rather than simply answering
yes or no.

- Allow the patient to recount his own story spontaneously without unnecessary interruption.

HISTORY OF PRESENT ILLNESS (HPI):

Chief Complaint (Unsa ang rason nga nagpa-admit?) / What brings you to the hospital? / Tell me about your problem

- Patient’s own words or phrases, Precise medical language, Symptom (if not symptom: a physical finding, lab finding,
continuing treatment: chemo or dialysis)

Characteristic / Quality (Unsa man ang sakit? Ga tusok-tusok? Huot? Gikumot?):

- Usual descriptors, unusual descriptors

- Type of Symptom/Quantity

- Sharp, lancinating, pressing, throbbing, colicky, crampy, burning, gnawing, dull, feeling of heaviness, etc.

Location and radiation (Asa dapit? Diha ra nabati or apil ang lain nga part sa lawas?) / Point the exact anatomic region

- Precise location, Deep or superficial, Localized or diffused, Where does it radiate?

Chronology/Onset/Duration: when it first began, sudden/gradual, continuous/intermittent (Kanus-a nagsugod? Unsa ka

dugaya? Gapadayon or putol-putol? Kalit lang or hinayhinay? Nagka grabe ang sakit or nagkawala?):

- How long does the symptom last? Frequency: continuous/intermittent (ex: pain is continuous for 10 hours, pain lasts for
2-3 hours, occurring 3 times daily

- Usually stated as number of hours, days, weeks, months, years before admission/consultation

- Enumerate symptoms as they appear PTA prior to admission (ex: 1 month PTA, 1 week PTA, 1 day PTA)

- Duration of symptom, periodicity of symptom, course of symptom: short term or long term

- Any previous treatment?

Setting (Under what circumstances does it take place) (Unsa man imong gibuhat usa ni sakit? Or kada kanus-a man mu
sakit?): - factors that triggered symptom, if no trigger use term “spontaneous” prior to symptom

Associated Factors / Symptoms associated (Unsay lain nga symptomas nga nabati?):

- Symptoms related to the organ system affected

See Past experience with symptom(s) next page

- Inquire about relevant non-symptom data (in Px w/ more than 1 problem, inquiry in multiple systems required)

- Important to know data on medications, treatments, doctors, hospital stays

Severity/Quantity: pain scale, how it affects daily activity, wakes him up at night (Unsa ka sakit? 1-10?

Unsay epekto sa adlaw-adlaw nga buluhaton? Kung matulog, pukawon ba ka sa kasakit?):

- Intensity or severity, Impairment or disability, Numeric description (pain scale, number of events, size? Volume?)

- Patient’s Perception: patient’s interpretation of his symptom & how it affects daily activities, lifestyle, personal and
interpersonal relationships; ex: Px feels his pain is life-threatening

- describe as MILD, MODERATE, SEVERE

- (Intensity) MILD – little or no effect to daily activities; MODERATE – there is limitation to daily activities; SEVERE –
unable to perform daily activities

- (Progression) Describe progress of pain as to improving, worsening, or unchanged

Exacerbating / Aggravating factors (Unsa may makapa grabe?):

- Any factors, therapeutic regimen or medications that aggravates the problem

- Emotional stress, physical stress, Food, Diet, Alcohol, Drugs, Environment

Relieving / palliating factors (Unsa may makapa alebyo?):

- Any factors, therapeutic regimen or medications that relieves the problem

Past experience with symptom(s) (Nakasulay na ug bati aning mga symptomas sauna?)

a. Prior treatment? Response? Data from past charts? (Unsa may gi tambal or gihimo? Naayo ba?)

b. What has patient done about the symptom(s)

PAST MEDICAL HISTORY

In the past medical history, inquire about medical issues and events not directly related to the HPI

(. Start with open-ended questions (eg, "How was your health as a child?") and then focus as needed with closed-ended
questions to establish details (eg, "Did you have chicken pox? Measles?")

Inquire about general state of health and past illnesses

" Childhood: measles, mumps, rubella, chicken pox, scarlet fever, and rheumatic fever
" Adult: hypertension, cerebrovascular accident, diabetes, heart disease, tuberculosis, venereal disease, cancer

Inquire about past injuries, accidents, psychotherapy, unexplained problems

• Elicit past hospitalizations (medical, surgical, obstetric, and psychiatric)
• Review the patient's immunization history
" Childhood: measles, mumps, rubella, polio, hepatitis B, chicken pox, tetanus/pertussis/diptheria
" Adult: tetanus boosters, hepatitis B, hepatitis A, influenza, pneumococcal pneumonia

Elicit past hospitalizations (medical, surgical, obstetric, and psychiatric)

Gynecologic: diseases affecting the female reproductive organs

Blood transfusion: date received, indications and transfusion reactions

Psychiatric: history of violence, suicidal attempts, drug overdose, and substance abuse

Review the patient's immunization history

• Review the patient's immunization history

“Childhood: measles, mumps, rubella, polio, hepatitis B, chicken pox, tetanus/pertussis/diptheria

“Adult: tetanus boosters, hepatitis B, hepatitis A, influenza, pneumococcal pneumonia

Obtain the patient's obstetric history and menstrual history

“Age of menarche, cycle length, length of menstrual flow, number of tampons/pads used per day

“Number of pregnancies, complications; number of live births, spontaneous vaginal deliveries/ cesarean sections;
number of spontaneous and therapeutic abortions
“Age of menopause

List current medications, including dose and route

“Ask specifically about over-the-counter medicines, alternative remedies, contraceptives, vitamins, laxatives

Review allergies

“Environmental, medications, foods

“Ensure that medication "allergies" are not actually expected side effects or nonallergic adverse reactions

PAST MEDICAL HISTORY

Illness/ Surgeries/ Injury/ Toxins or Industrial Exposure/ Trauma/ Childhood Dse

Age Date Description/Dx/Mgt (note blood transfusion) Hospital/Clinic

Chickenpox/
Hangga

Measles/
Tipdas

Mumps/
Bayook

Dengue

Malaria

Typhoid/Tipus

Polio

Tetanus

TB

Hepatitis

Hypertension

Diabetes

Cancer

Asthma/Hubak

Surgery/Operahan/
Tahi/Aksidente

Blood Transfusion/
 Naabonohan

Others

Immunizations
Type Age Type Age
Diphtheria Hepatitis
Pertussis Mumps
Tetanus Measles
Rubella Influenza
Polio Others

FAMILY HISTORY
1. Inquire about age and health (or cause or death) of grandparents, parents, siblings, and children
2. Ask specifically about family history of:

• Diabetes • Kidney disease

• Tuberculosis • Asthma
• Cancer • Tobacco use
• Hypertension • Alcoholism
• Stroke • Weight problems
• Heart disease • Mental illness – depression, suicide, schizophrenia,
• Hyperlipidemia multiple somatic concerns
• Bleeding problems • Symptoms similar to those the patient is experiencing
• Anemias

Disease with heredo-familial tendency: Stroke, Cancer, Hypertension, Diabetes

Mellitus, Heart Diseases, Blood disorders, Allergies, Arthritis, Obesity, Alcoholism,

Psychiatric illnesses, Seizure Disorder,

Kidney diseases, etc., Communicable diseases: Tuberculosis, sexually transmitted infections (STI), etc.

Any member of the family with similar symptoms.

FAMILY HISTORY (If present x if cause of death (indicate age and year of death)
 Grandparents Father’s side Mother’s side

Father
Mother
Siblings
Children
Others

PERSONAL/SOCIAL HISTORY

Marital Status: Name of Spouse: Age of Spouse:

Educational attainment: Health condition of spouse:

Children: Age: : : : : : : : :

Sex: : : : : : : : :

Household composition/Living Situation (Kinsa ang kuyog sa panimalay?):

Housing:

Living conditions, source of water, waste disposal:

Occupational history (nature of work, number of hours of exposure to hazards, safety measures used)

Sources of social support (Asa/Kinsa gikan ang supporta? Financial? Emotional?):

Sources of stress (Kinsa or unsa gikan ang stress or kaguol?):

Coping styles (Unsa ang ginahimo kung maguol or ma stress para mahuwasan?):

Hobbies/Leisure activities (Unsa ang kalingawan?):

Religious affiliations and beliefs (Relihiyon?):

Activities of Daily Living (especially for elderly) (Unsay ginahimo/buluhaton adlaw-adlaw?):

Exercise:

Sleep:

Diet (Unsa ang ginakaon?):

Dietary supplements/restrictions (Gi inom nga tambal/maintenance or mga gi bawal? Drug reactions/allergies):

Coffee, tea, caffeinated (tig-inom ug kape/ tsa):

Safety measures:
Alternative health care practices (Unsay lain ginahimo para sa panglawas?):

Smoking habit: age started: _______quit:______ type:_________ sticks/packs per day:____

Alcohol Use: age started: _______ quantity__________ frequency:_________ type:_______

Illicit Substance use (Tig gamit ug droga/marijuana):

OBSTETRIC/MENSTRUAL HISTORY

Menarche (Sugod sa dugo): Menopause:

Menstrual Flow Interval (Kada ika pila ka adlaw dug-on?):

Duration (Unsa ka dugay): Amount (Unsa ka daghan):

LMP (Kanus-a last gidugo?):

( ) Vaginal Discharge ( ) AbN bleeding ( ) Mammogram ( ) Others:

( ) Pelvic Pain ( ) History of STI ( ) Pap Smear

OB History: G(Gravidity-no. of pregnancies): P(delivery of live babies): A: L:

Pregnancies:

Full Term: Postmature:

Premature: Abortions:

Sexual history (exposure and history of STIs, number and variety of partners)

( ) Impotence ( ) Difficulties ( ) Others

Breasts
( ) Masses (Bukol) ( ) Pain ( ) Others
( ) Discharge ( ) Trauma

REVIEW OF SYSTEMS
General
( ) Recent weight change (Pagbag-o sa timbang) ( ) Overall weakness (Kaluya) ( ) Fever, Chills and Sweats
( ) Sleep disturbance ( ) Fatigue/ Malaise (Gil-as/Kabudalay) ( ) clothing that fits more tightly or loosely than before

Skin
( ) Itching (katol-katol) ( ) Moles (alom) ( ) Skin Color change ( ) Lumps (bukol) ( ) Rash
( ) Pigmentation ( ) Vasomotor changes ( ) dryness ( ) Photosensitivity ( ) Hair ( ) Nails

Head and Neck

( ) Headache ( ) Neck stiffness ( ) lightheadedness (gaan ang ulo) ( ) Dizziness(lipong)
( ) Swollen glands ( ) goiter ( ) lumps

Eyes
( ) Spots in visual fields ( ) Flashing lights ( ) Transient vision loss
( ) Double/blurred vision ( ) Blind spot ( ) Red, Painful eyes
( ) Itching and tearing ( ) glasses/contact lenses ( ) Cataract/ Glaucoma

Ears, Nose, Sinuses, Mouth, Throat

( ) Sore throat ( ) Frequent colds ( ) nasal stuffiness ( ) nasal discharges
( ) nose bleed ( ) sinus trouble ( ) bleeding gums ( ) dentures
( ) last dental exam ( ) dry mouth ( ) sore tongue ( ) hoarseness
( )hearing ( ) tinnitus ( ) vertigo ( ) earaches
( ) hearing aids

Respiratory
( ) Cough ( ) hemoptysis ( ) pleurisy ( ) SOB ( ) Sputum (color,quantity)
( ) wheezing (kutas) ( ) chest tightness ( ) asthma ( ) pneumonia
( ) bronchitis ( ) emphysema ( ) exercise intolerance

Cardiovascular
( ) heart trouble ( ) palpitations ( ) edema
( ) high blood pressure ( ) dyspnea (w/ or w/ exertion) ( ) ECG tests
( ) rheumatic fever ( ) orthopnea ( ) CV tests
( ) chest pain/discomfort ( ) paroxysmal nocturnal dyspnea

Gastrointestinal
( ) dysphagia ( ) bowel movements ( ) rectal bleeding
( ) indigestion/heartburn ( ) stool color/size ( ) constipation/diarrhea
( ) appetite/weight loss ( ) change in bowel habits ( ) abdominal pain
( ) nausea,vomiting,hematemesis ( ) pain with defecation ( ) food intolerance
( ) excessive belching/flatulence ( ) jaundice ( ) hepatitis

Peripheral Vascular
( ) intermittent claudication ( ) leg cramps ( ) varicose veins
( ) swelling with tenderness/redness ( ) change in fingertips/toes

Urinary
( ) frequency of urination ( ) polyuria/oliguria ( ) nocturia
( ) urgency ( ) dysuria (onset) ( ) flank pain
( ) hematuria ( ) kidney stone ( ) suprapubic pain
( ) incontinence ( ) hesitancy /dribbling

Genital
( ) hernia ( ) discharge/sores ( ) sexual habits
( ) birth control ( ) condom use ( ) age of menarche
( ) regularity ( ) duration ( ) amount
( ) bleeding during intercourse ( ) LMP ( ) itching and abnormal discharge

Musculoskeletal
( ) Joint stiffness () Low back pain ( ) Muscle pain
( ) Cramps ( ) Weakness ( ) Difficulty moving or walking
( ) Able to climb up and down stairs ( ) Trauma ( ) Swelling ( ) Restriction of movement/fx

Endocrine
( ) Thyroid trouble ( ) Salt cravings ( ) hirsutism/alopecia
( ) Heat/cold intolerance ( ) Excessive thirst/hunger ( ) quality of hair
( ) Loss of sexual drive ( ) Excessive sweating

Hematopoietic
( ) Abnormal bleeding ( ) Pica ( ) Easy Bruising ( ) Frequent infection ( ) Anemia
( ) Swelling/Lumps/Bumps

Neurologic
( ) Fainting or passing out ( ) Loss of sensation (numbness) ( ) Memory disorder ( ) Seizures
( ) tingling (“pins and needles”) ( ) Headaches ( ) Weakness on one or both ( ) Dizziness
( ) Blackouts sides of the body ( ) Loss of balance/Lack of coordination ( ) Tremors

Psychiatric
( ) Nervousness/Anxiety ( ) Intrusive thoughts ( ) Auditory hallucinations
( ) Depression ( ) Loss of good judgment or insight
( ) Mania ( ) Visual hallucinations