(IM Ward) History Taking Tool PDF
(IM Ward) History Taking Tool PDF
(IM Ward) History Taking Tool PDF
Date: Informant:
History Taken By: Reliability:
IDENTIFYING DATA:
Name (First Name, Middle Name, Last Name):
Age: Gender: Civil Status:
Birthdate: (Month, Day, Year): Birth Place:
Present Address:
Nationality: Occupation: Religion:
Number of Times Admitted to this Hospital: Name of Hospital: Date of Current Admission:
CHIEF COMPLAINT:
PQRSTU of Pain:
P: Precipitating (Provocative)/ Aggravating/
Palliative (Alleviating or Relieving Factors)
Precipitating Factors: What brings out the
symptoms?
Aggravating Factors: What makes the
symptoms worse?
Palliative Factors: What relieves the
symptom?
Q: Quality (Character)/ Type of Symptom/ Quantity
What is the symptom like?
R: Region (Location) and Radiation of Symptoms
Ask if pain is localized, if not, to where does it
radiate
S: Severity/Intensity and its Progression
Mild little or no effect to daily
Moderate there is limitation to daily
activities
Severe unable to perform daily activities
T: Timing
Duration: How long does the symptom last?
Frequency: Continuous or intermittent (recur
at intervals)?
U: Understanding Patients Perception of Pain
Describe how the patient understands the
significance of pain
Immunizations Received:
B. Surgeries and Other Procedures Full details including type, date, results, and complications
E. Medications Prescribed, over-the-counter medications, and homeopathic remedies; and any adverse reactions
H. Psychiatric History of violence, suicidal attempts, drug overdose, and substance abuse
Children:
Grandparents (Maternal):
Grandparents (Paternal):
Grandchildren:
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.
PERSONAL AND SOCIAL HISTORY (PSH) OR FUNCTIONAL ASSESSMENT OR PERSONAL ACTIVITIES OF DAILY LIVING (ADL):
Education Attainment:
Marital Status Health condition of spouse:
Occupational History
Nature of Work:
Number of Hours of Exposure to Hazards:
Safety Measures Used (Past and Present):
Interpersonal Relationships and Financial Resources Within and Outside the Family:
Living Conditions:
Source of Water:
Waste Disposal:
Relevant Travel History:
Habits:
Sleep and Rest Pattern:
Self-Care:
Activities:
Exercise:
Sexual History:
Exposure and History of STI:
Number and Variety of Partners:
Premenstrual Symptoms:
REVIEW OF SYSTEMS:
1. CONSTITUTIONAL SYMPTOMS: 2. SKIN: 3. HEAD:
___ Significant Change in Weight ___ Itchiness ___ Headache
___ Generalized Body Weakness ___ Excessive dryness or sweating ___ Dizziness
___ Fatigue ___ Cyanosis ___ Vertigo
___ Fever ___ Pallor
___ Chills ___ Jaundice
___ Increased Appetite ___ Erythema
4. EYES: 5. EARS: 6. NOSE AND SINUSES:
___ Pain ___ Earache ___ Changes in Smell
___ Blurring of Vision ___ Deafness ___ Nose Bleeding
___ Double Vision ___ Tinnitus ___ Nasal Obstruction
___ Lacrimation ___ Ear discharge ___ Nasal Discharge
___ Photophobia ___ Pain Over Paranasal Sinuses
___ Use of Eye glasses
7. MOUTH AND THROAT: 8. NECK: 9. BREAST:
___ Toothache ___ Pain ___ Pain
___ Gum Bleeding ___ Limitation of Movement ___ Lumps
___ Disturbance in Taste ___ Mass ___ Nipple Discharge
___ Sore Throat
___ Hoarseness
10. RESPIRATORY: 11. CARDIOVASCULAR: 12. GASTROINTESTINAL:
___ Pleuritic Chest Pain ___ Palpitations ___ Abdominal Pain
___ Cough ___ Syncope ___ Nausea
___ Sputum Production ___ Easy Fatigability ___ Vomiting
___ Hemoptysis ___ Dysphagia
___ Audible Wheezing ___ Diarrhea
___ Constipation
___ Hematemesis
___ Melena
___ Hematochezia
___ Regurgitation
13. GENITOURINARY: 14. EXTREMITIES: 15. NERVOUS:
___ Dysuria ___ Edema ___ Loss of Consciousness
___ Urinary Frequency ___ Swelling of Joints ___ Focal Weakness
___ Urgency ___ Stiffness ___ Parethesia
___ Hematuria ___ Numbness ___ Speech Disorder
___ Incontinence ___ Intermittent Claudication ___ Loss of Memory
___ Genital Pruritus ___ Limitation of Movement ___ Confusion
___ Urethral Discharge
16. HEMATOLOGIC: 17. ENDOCRINE:
___ Bleeding Tendency ___ Intolerance to Heat and Cold
___ Easy Bruising ___ Polydipsia
GENERAL SURVEY:
A. Assess the LEVEL OF CONSCIOUSNESS
Normal: Awake, alert, responds appropriate to verbal, tactile, and painful stimuli
Impaired: Agitated, restless, drowsy, stuporous, lethargic
May obtain Glasgow Coma Scale (GCS)
B. ORIENTATION to time, place, and person
C. APPEARANCE
Assess the relationship of the biologic age with the chronological age (Does patient look his stated age? Younger or older?)
Manner of dressing and personal hygiene (appropriate, well-kempt neat and clean, unkempt dirty)
D. ATTITUDE AND BEHAVIOUR (cooperative/uncooperative, rational/irrational, friendly/hostile, interested/indifferent)
E. SPEECH AND LANGUAGE
Assess the quantity, rate, loudness (tone), fluency, slurring
Possible findings: aphasia/dysphasia, dysphonia, dysarthria
F. MEMORY, MOOD AND AFFECT
Memory (immediate, recent, remote)
Mood (euthymic/normal, dysphoric/sad, euphoric/elated, angry, anxious, apathetic, etc.)
Affect (appropriate or inappropriate)
G. NUTRITIONAL STATUS (underweight, normal weight/well-nourished, overweight, obese)
BMI = weight in kg/(height in m)2
H. GAIT AND POSTURE
Ask the patient to stand straight and observe posture (normal erect and straight, abnormal stooping)
Ask the patient to walk and observe gait (normal, abnormal limping, shuffling, staggering)
If unable to walk (wheelchair-borne)
I. BODY BUILT (slender, short, tall, lanky, stout)
Sthenic Type (Athletic type)
Hypersthenic (short and stocky)
Hyposthenic (thin and developed)
Asthenic (malnourished marasmus or kwashiorkor)
J. SIGNS OF DISTRESS
Check for objective evidence of:
Dyspnea (flaring od alae nasi, use of accessory muscles of respiration, intercostal retractions, active contractions of the SCM)
Cyanosis
Agitation or restlessness
Pallor
Cold-clammy respiration
Chest pain
VITAL SIGNS:
A. BLOOD PRESSURE
B. CARDIAC RATE (beats per minute)
Assess rate and rhythm
C. PULSE RATE (beats per minute)
Assess rate, volume, and rhythm
Amplitude (strong or weak)
D. RESPIRATORY RATE (cycles per minute)
E. BODY TEMPERATURE
F. WEIGHT (kg)
G. HEIGHT (cm)
EXAMINATION OF EYES
A. EYEBROWS (amount, distribution, lesion)
B. EYELIDS (swelling, edema, erythematous rim, ptosis lesions)
C. PALPEBRAL FISSURES (normal, widened, or narrowed)
D. EYEBALLS
1. Exopthalmos (protruding eyeballs) or Enopthalmos (sunken eyeballs)
2. Lid Lag Test
With your finger or holding a penlight as a target in the midline above the eye level, about 20 inches (50 cm) away, move the target rapidly downward in
the midline, watching for the appearance of white sclera between the iris and the upper eye lid margin.
E. EYELASHES
1. Direction of Growth
2. Matting of Eyelashes
F. CONJUNCTIVAE AND SCLERAE
1. Color of Sclerae (white or icteric)
2. Color of Palpebral Conjunctivae (pinkish, congested, injected, pale)
3. Look for any growth or edema
G. CORNEA (transparency or clarity, scars, abrasions and ulcers of the cornea)
H. IRIS, PUPILS AND LENS
1. Color of IRIS
2. PUPILS
a. Size (measure the diameter of each pupil in mm)
b. Shape
c. Symmetry
d. Reaction to Light
Pupillary Light Reflex (Direct and Indirect/Consensual Response)
Swinging Flashlight Test (Move the light from one pupil to the other, back and forth)
Accomodation Reflex
3. LENS (transparency, opacity)
I. EXTRAOCULAR MOVEMENTS
H Pattern
Observe for Nystagmus
J. OPHTHALMOSCOPIC EXAMINATION
Note for the following:
1. Clarity of the disc outline (Nasal outline may be normally somewhat blurred)
2. Color of the disc (Normally yellowish orange to creamy pink)
5. Deformities
B. BUCCAL MUCOSA
1. Color
2. Pigmentation
3. Ulcers
4. Patches
5. Nodules
C. GUMS
1. Color
2. Swelling
3. Bleeding
4. Retraction
5. Discoloration
6. Recession of the Gingival Margins
7. Pus in the Margins
8. Presence of lead and bismuth line
D. TEETH
1. Absence of one or more teeth
2. Presence of carries
3. Discoloration
4. Fillings
5. Bridges and braces
E. ROOF (PALATE) AND FLOOR OF THE MOUTH
1. Color
2. Deformities
3. Any lesions and masses
4. Odor (alcohol, ammonia, sweetish fruity odor of acetone, musty odor, halitosis)
F. TONGUE
1. Observe for abnormal movements (fasciculations, tremors)
2. Observe for the following:
a. Size
b. Color
c. Surface
d. Moisture
e. Symmetry
f. Lesions
G. SOFT PALATE, UVULA, TONSILLAR PILLARS, TONSIL, AND POSTERIOR PHARYNGEAL WALL
1. Color
2. Symmetry
3. Any evidence of exudates
4. Swelling
5. Ulcerations
6. Tonsillar enlargement
7. Induration or tenderness
Description of Normal Findings:
Lips: pinkish, moist, symmetrical, no lesions
Buccal Mucosa and Gums: pink, smooth, no lesions
Teeth: complete set, no dental carries, good oral hygiene
Roof, Floor and Palate: pinkish, no lesion
Uvula in midline, tonsils not enlarged, pharynx is pink, no lesions, no exudates
B. Observe how the patient carries his head (position: tilted, rotated) and note the tone of the neck muscles
C. Range of Motion
1. Flexion (chin to chest)
2. Extension (look at the ceiling)
3. Lateral Rotation (chin to shoulder)
4. Lateral Flexion/Bending (ear to shoulder)
PALPATION OF THE NECK
A. In front of patient: posterior cervical spine, mastoid process, trapezius and sternocleidomastoid
B. Behind the patient: thyroid gland, lymph nodes
If a mass is palpable, describe its location, consistency, size, and mobility
PALPATION OF TRACHEA
Palpate the trachea for any deviation
PALPATION LYMPH NODES
1. Preauricular
2. Posterior auricular
3. Occipital
4. Tonsillar
5. Submandibular
6. Submental
7. Superficial cervical
8. Posterior Cervical Chain
9. Deep Cervical Chain
10. Supraclavicular
PERCUSSION
AUSCULTATION
A. Determine the characteristics of the different breath
(lung) sounds
1. Vesicular
2. Bronchial
3. Bronchovesicular
4. Tracheal
B. Listen for and identify any adventitious (added) sounds
(crackles, wheezing)
C. Listen to the sounds of the patients spoken and
whispered voice as they are transmitted to the chest
wall
1. Bronchophony (99, 99 or tres tres)
2. Egophony (eee)
3. Whispered Pectoriloquy (Whisper 99, 99 or tres
tres)
C. CN III, IV, VI: OCCULOMOTOR NERVE, TROCHLEAR NERVE, AND ABDUCENS NERVE
1. Direct Light Reflex
2. Indirect or Consensual Light Reflex
3. Convergence or Accommodation Test
4. Levator Palpebrae Muscle (Lid Elevation)
Measure the size of the palpebral fissure in mm
5. Extra-ocular Muscle
6 Cardinal Gaze (H Pattern)
Superior Oblique Test (Note if there is symmetry in position of eyeballs)
Nystagmus
D. CN V: TRIGEMINAL NERVE
1. Test for Sensory Function
a. Facial Sensation (blunt and sharp forehead, cheeks, and jaw)
b. Corneal Reflex
2. Test for Motor Function
a. Contraction of temporalis and masseter muscle (clench teeth or bite)
b. Deviation of lower jaw (open and close mouth)
c. Resist force to close mouth (apply pressure on the chin)
3. Jaw Jerk Reflex
Open mouth, place top of your left index finger on his chin and tap with a reflex hammer