1. CLINICAL HISTORY

2. Diagnosis in Medicine - Clinical history - Physical Examination
- Investigations

3. Clinical history Patient’s profile Chief complaint
History of the present illness
Systemic review
Drug history
History of allergy
Past history
Family history
Socioeconomic history

4. Patient’s Profile Name Age Sex Marital status Area of residence
Education
Occupation
Setting of the interview:
- Place
- Time and date

5. Chief Complaint
Main symptom(s) or other abnormalities (may be a sign or lab abnormality) which brought the patient to medical attention and its duration.

6. History of the present illness
Includes details of the chief complaint
- Mode of onset
- Course and progression
- Duration
- Site, character, Severity and Frequency: as applicable
- Precipitating and relieving factors
- Development of other symptoms since onset of disease till the time of the interview in a chronological order and the relation of these symptoms to the chief complaint.
- Mention other symptoms or relevant data related to the system affected if they are negative or positive.

7. Example Chief complaint: Chest pain Present history:
- Mode of onset: sudden, gradual, episodic--
- Course: progressive, intermittent, decreasing---
- Site
- Radiation
- Character
- Severity
- Duration
- Frequency and periodicity
- Special times of occurrence
- Precipitating factors
- Aggravating factors
- Relieving factors
Associated symptoms and their relation to pain
Risk factors for ischemic heart disease as cigarette smoking, diabetes, hyperlipidemia…

8. Chest pain
Patient was doing well till yesterday when he had sudden onset of central chest pain which started while he was walking uphill, relieved 10 minutes after rest, pain was severe, burning in nature, radiating to left shoulder and back, associated with sweating and dizziness. He had no SOB during the pain, and no palpitation. He has no history of diabetes or hypertension. He smokes 20 cigarettes/day. Has no family history of IHD.

9. Attacks of SOB
Patient with history of bronchial asthma for last 3 years with recurrent attacks, was doing well till today morning when he started to have sudden onset of SOB with wheezing and cough with production of tenacious sputum for last 6 hours, worsening with time in spite of using inhalers. Has no fever, no hemoptysis and no chest pain. He gives history of similar attacks over last 3 years, precipitated by URT infection, exposure to perfumes and dust with improvement on inhalers. He is relatively free between the attacks. No history of hospitalization before.

10. Systemic review
Inquiry about all symptoms of the various systems if they are positive or negative recently

11. General symptoms -May be present in diseases of any system
- Fever, general weakness, fatigue, malaise, anorexia, loss of weight

12. Cardiovascular symptoms
- Chest pain
- Shortness of breath
*orthopnea
* paroxysmal nocturnal dyspnea
- Palpitation
- Ankle swelling
- Dizziness, syncopal attacks, fatigue
- Intermittent claudication

13. Respiratory system URT symptoms:
Sneezing, nasal discharge, epistaxis, nasal obstruction, sore throat, hoarseness of voice, stridor
LRT symptoms:
Chest pain
Shortness of breath
Cough and sputum
Wheezing
Hemoptysis

14. Gastrointestinal symptoms
Difficulty or pain with swallowing: dysphagia/ odynophagia
Nausea and vomiting
Heartburn, regurgitation
Abdominal pain
Abdominal distension
Disturbances in bowel habits: constipation or diarrhea
Anal pain, discharge or itching
Hematemesis, rectal bleeding (hematochezia) or melena.

15. Urinary symptoms Renal pain Dysuria,
Frequency of micturition: nocturnal frequency
Disturbed stream of micturition
Discoloration of urine
Amount of urine: polyuria, oliguria, anuria

16. Musculoskeletal system
- Joint pain
- Joint swelling
- Limitation of movements in various joints.
- Muscle pain and muscle wasting
- Bone pains
- Deformities

17. Dermatological symptoms
Skin rash
Itching
Pain
Swellings
Disturbance in pigmentation
Bleeding into skin
Disturbances in hair: hirsuitism, alopecia, hair fall
Disturbances in nails

18. Genital tract symptoms
In males:
Erectile dysfunction, disturbances in ejaculation, urethral discharge, sexual history
In females:
Age of menarche / menopause
Regularity of menstruation
Vaginal discharge, pruritis
Amount of menstrual bleeding
menstrual pain
Sexual history
obstetric history: number of pregnancies, number of abortions, number of deliveries, mode of delivery

19. Neurological symptoms
Disturbance in level of consciousness
Headache
Fits
Special senses: hearing, taste, vision, smell
Speech disturbances
Disturbances in sleep
Motor /sensory deficits,
Disturbances in gait
Sphincteric disturbances.

20. Endocrinological symptoms
Cold or heat intolerance,
Excessive sweating
Change in weight
Polyuria, polydipsia
General weakness and fatigue

21. Hematological symptoms
Symptoms of anemia:
pallor, general weakness, easy fatigability , exertional dyspnea and palpitaion
Recurrent fevers
Bleeding tendency: usually from more than one site
Neck or abdominal swellings

22. Psychiatric Symptoms History of traumatizing events
Anxiety, depression, obsession
Fear of certain diseases,
Mental illnesses.

23. Important comment:
Any symptom found during enquiry for systemic review should be analyzed regarding severity, frequency, duration, any relieving or precipitating factors, and medications received

25. Drug history - Details of all recent drugs taken by the patient
- Details of drugs taken in the past for long periods
- Any reaction or side effects to drugs

26. History of allergy - Any allergy to drugs, food, pollens, clothes
- Type of reaction: itching, urticaria, skin rash, respiratory difficulty, eye symptoms….

27. Past history - History of similar attacks in the past
- History of diseases in the system involved in the past.
- History of hospitalization
- History of operations
- History of major non operative trauma.
- History of severe acute illnesses
- History of chronic illnesses
- History of blood transfusion
- History of vaccination
- History of recent travel

28. Family history - History of similar diseases in close relatives
- History of family diseases in the involved system
- History of chronic illnesses in family members
- History of major acute illnesses recently

29. Socioeconomic history
- marital status and children
- level of education
- income
- living circumstances
- recent jobs
- hobbies
- cigarette smoking
- alcohol drinking
- drug abuse

30. Summary of clinical History
Includes: name, age, chief complaint and its duration, major associated positive symptoms and related data, major past or family diseases.

31. Differential diagnosis
Various possibilities for patient presentation arranged in an ordered way from the most likely diagnosis to the least likely one.

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