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History Taking

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Anna Baumer Machado
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132 views4 pages

History Taking

Uploaded by

Anna Baumer Machado
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

History Taking:

1. Identifying Information:

 Name
 Age
 Gender
 Occupation
 Contact Information

2. Chief Complaint (CC):

 The main reason for seeking medical attention

3. History of Present Illness (HPI):

 Chronology of symptoms
 Associated symptoms
 Aggravating and alleviating factors

4. Past Medical History (PMH):

 Previous illnesses
 Surgical history
 Hospitalizations
 Allergies
 Medications (including over-the-counter, supplements, and
herbal remedies)

5. Family History:

 Diseases or conditions that run in the family

6. Social History:

 Smoking status
 Alcohol use
 Recreational drug use
 Occupation hazards
 Sexual history
 Diet and exercise habits

7. Review of Systems (ROS):

 General: Fever, weight loss, fatigue


 Cardiovascular: Chest pain, palpitations
 Respiratory: Cough, shortness of breath
 Gastrointestinal: Appetite changes, nausea, vomiting, bowel
habits
 Genitourinary: Urinary frequency, urgency, nocturia
 Neurological: Headache, dizziness, weakness, numbness
 Musculoskeletal: Joint pain, stiffness
 Skin: Rashes, itching

Physical Examination:

1. General Appearance:

 Level of consciousness
 Signs of distress

2. Vital Signs:

 Temperature
 Blood pressure
 Pulse rate
 Respiratory rate
 Oxygen saturation

3. Head and Neck:

 Inspection of head, face, neck


 Palpation of lymph nodes
 Examination of eyes, ears, nose, throat

4. Cardiovascular:

 Inspection and palpation of precordium


 Auscultation of heart sounds
 Palpation of peripheral pulses

5. Respiratory:

 Inspection of chest
 Palpation of chest wall
 Percussion of lung fields
 Auscultation of breath sounds

6. Abdominal:

 Inspection
 Auscultation of bowel sounds
 Palpation
 Percussion

7. Neurological:

 Mental status examination


 Cranial nerve examination
 Motor and sensory examination
 Reflexes

8. Musculoskeletal:

 Inspection
 Palpation
 Range of motion
 Strength testing

9. Skin:
 Inspection for lesions, rashes, discoloration

10. Additional Examinations (if indicated):

 Gynecological examination
 Rectal examination
 Extremities examination

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