Comprehensive Patient History: Key Factors & Systems
Comprehensive Patient History: Key Factors
Marital Status (Current and Past)
Indicates whether the patient is single, married, divorced, or widowed.
Schooling
Sheds light on social and cultural status.
Occupation (Current and Previous)
Reflects social status, physical effort, psychological trauma, exposure to substances or harmful agents, and various disorders that can cause disease.
You must ask the patient if their partners recognize related illnesses in the working environment.
Hereditary Background
- Investigate etiology and disease morbidity and mortality in grandparents, parents, children, spouses, siblings, extended family, and cohabitants.
- Investigate consanguinity, birth, abortions, allergies, neoplasms, obesity, malnutrition, surgery, alcoholism, and addiction.
Personal History (Non-Pathological)
- Room
- Food
- Hygiene
- Sport and exercise
- Immunizations and sera
- Work-rest and sleep
- Interests and hobbies
- Family integration
- Attitude towards life and problems
Personal History (Pathological)
- Alcoholism
- Smoking
- Addiction
- Congenital diseases
- Childhood diseases
- Surgical history
- Traumatic history
- Allergic history
- Transfusion history
- Poisoning
- Hospitalization
- Laboratory and cabinet studies
- Disease-treatment employed
Integument
- Skin: Color, pigmentation, temperature, humidity, rashes, itching, peeling, bruising, hemorrhage.
- Hair: Color, texture, abnormal growth or loss, distribution.
- Nails: Color changes, brittleness, ridges, dimples, curvature.
Special Senses
- Ear: Deafness, tinnitus, dizziness, ear discharge, pain, mastoiditis, operations.
- Nose: Runny nose, rhinitis, sinusitis, discharge, obstruction, epistaxis.
- Mouth: Mouth or tongue swelling, symptoms related to the teeth.
Cardiovascular
Palpitations, tachycardia, regular rhythm, chest pain, dyspnea, cough, cyanosis, ascites, edema, intermittent claudication, cold extremities, phlebitis, change in skin color or standing posture, hypertension, rheumatic fever.
Urinary
Color of urine, polyuria, oliguria, nocturia, dysuria, hematuria, pyuria, urinary retention, frequent urination.
Genital
Menstrual history: Age of initiation, frequency during periods, regularity, duration, number of flow, leukorrhea, dysmenorrhea, dates of last normal period and the preceding, the date and nature of menopause, and so on.
Digestive
Appetite, weight changes, dysphagia, nausea, belching, flatulence, abdominal pain or cramps, vomiting, hematemesis, jaundice (pain, fever, intensity, length, color of urine), feces (color, frequency of stools, consistency, smell, fumes, cathartics), hemorrhoids.
Hemolymphatic
Lymph nodes: Enlarged, pain, oozing, draining sinuses, location.
Endocrine
History of growth, configuration, and body weight. Size of hands, feet, and head, and especially changes in adulthood hair distribution. Skin pigmentation. Weakness. Goiter, exophthalmos, dry skin and hair, intolerance to heat or cold, tremor. Polyphagia, polydipsia, polyuria, glycosuria. Secondary sexual characteristics, impotence, sterility, etc.
Special Examinations
- Neurological
- Fundus
- Dermatological
- Pulse