Case History – Examination on admission

Case History
 
Basic Information
 
Family History
 
Social History
 
Pharmacological Anamnesis
 
Allergic Anamnesis
 
Gynaecological Anamnesis
 
Personal History
 
Current Disease
 
 
Case 1
 
Case 2
 
Case 3

Basic Information
 

	Basic information: first name, surname, title, personal identification number (PIN), address, post code, telephone number, health insurance company, admitted to the Clinic of Internal Medicine of Motol Teaching Hospital on (date)…. at (hour, min.)
	Cause of admission: brief accurate information on the reason for admission (e.g. protracted retrosternal pain accompanied by dyspnoea).
	In repeated hospitalisations, the date of the last hospitalisation.
	Closest relatives – contact address, telephone number/s.

 
FH - Family History
 

	If father and mother are still living , they died, their age at death and their last diagnosis/cause of death.
	Brothers, sisters, children.

Ask targeted questions concerning the familial occurrence of the following diseases: coronary heart disease (CHD), myocardial infarction (MI), cerebrovascular accident (CVA) – ipresence of or death due to vascular disease before 50 years of age in men and 55 in women is significant from epidemiological viewpoint, hypertension, diabetes mellitus (DM), neoplastic disease, tuberculosis, infectious hepatitis, neurological or psychiatric dieases.
 
SH - Social History:
 

	Marital status - married, divorced, lives alone, etc.
	Accommodation arrangements - which floor, elevator, up the hill, etc.
	Occupation - physically demanding, stress, pollutants, risk at workplace, etc.
	Retired - old age pensioner, disabled, reason for the disability pension, since when.

 
PA - Pharmacological Anamnesis:
 
List of permanently taken medications including their dosing.
 
AA - Allergic Anamnesis
 

	Drug allergy – kind and type of allergic reaction (exanthema, allergic oedema, anaphylactic shock), when the reaction occurred.
	Hay fever (pollinosis), allergy to dust, pollen, mites.
	Food allergy.
	Allergy to adhesive plaster etc.
	Allergy to contrast media.

 
GA - Gynaecological Anamnesis
 

	Menstruation – from - to, regular, irregular, date of the latest menstruation.
	Menopause - at what age, hormone replacement therapy.
	Number of children, number of spontaneous miscarriages or abortions.
	Gynaecological surgeries.
	Hormone contraceptives.

 
PH - Personal History
 
Chronological list of illnesses from childhood up to present date (dates to be given either in the form of the year or the age of the patient – should not be mixed, definitely not in the form of how many years ago)
 

	Children's infectious diseases (rubella, mumps, chicken-pox, scarlet fever, diphtheria), repeated tonsillitis, rheumatic fever (protracted febrile disease in childhood accompanied with joint swelling, or resulting in heart murmur).
	Operations.
	Injuries.
	Habits: smokes from - to, how many cigarettes a day, how long, date of giving up. alcohol – beer, wine, spirits, how much per day on average, regularity of consumption coffee – how many cups per day other habits.

 
Ask about diseases of all body systems such as coronary heart disease (CHD) chest pain myocardial infarction or cerebral stroke in the past.
 

	Treated for hypertension – for how long, what type of treatment.
	Diabetes mellitus (DM) Type 1or 2 , what type of treatment, other metabolic and endocrine diseases (thyreopathy etc.).
	Digestive disorders - i.e. gastroduodenal ulcer, gallbladder problems, cholecystolithiasis, biliary colic, icterus, infectious hepatitis, intestinal problems – diarrhoea, obstipation, body weight stable, unstable, weight gain or loss (how many kilograms and in what time course), reason – anorexia, bad eating habits, vomiting, slimming diet, stress etc. Stools regular, irregular, pathological substances in the faeces – blood, mucus, melena.
	Urological problems - dysuria, pollakisuria, cystolithiasis, renal colic, haematuria.
	Diseases of lower extremities: – claudication, venous – varicose veins, state after deep vein thrombosis, chronic venous insufficiency, varicosel ulcer, joint problems, state after injuries, fractures.
	Briefly neurological diseases.

 
CD – Current Disease
 
Complaints preceding hospital admission, their origin, circumstances and development. Detailed data in chronologicall order. Other signs and symptoms, results of investigations done so far, type of treatment and its effect.