MEDICAL SCHOOL

MEDICAL HISTORY

Subject: Medical English II

Semester: 2013 II
Academic cycle: VI
Teacher: YssicaGarca Snchez
Name: _______________________________________________________
Unit: ________________________________________________________

ECTOSCOPIA

a) Apparent state of gravity: _________________________________________

b) Apparent age: ___________________________________________________
c) Main signs: ______________________________________________________
ANAMNESIS
PERSONAL DETAILS:

a) Name:______________________________________________________
b) Age: ________________________________________________________
c) Date of birth: ________________________________________________
d) Gender: _____________________________________________________
e) Race: _______________________________________________________
f) Nationality: __________________________________________________
g) Marital status:_______________________________________________
h) Occupation:__________________________________________________
i) Level studies: ________________________________________________
j) Birth Place: __________________________________________________
k) Hometown:__________________________________________________
l) Admission date: ______________________________________________
m) Referral: ____________________________________________________

CURRENT DISEASE
Disease Onset: ________________________________________

How it starts:

a) Insidious

b) Progressive

c)Acute

Course of illness: _____________________________________

Main symptoms:

a) Headache

b) Stomachache

c) Runny nose

d) Fever ___

e) Others: _______

Chronological description:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
________

Appetite:____________________
Thirst: ______________________
Urine: _______________________
Feces: _______________________
Change in weight:_____________
Basal state: __________________
PHYSICAL EXAMINATION
Vital signs:

Blood pressure
Heart rate
Respiration rate
Temperature
Weight
Height
Body mass index
Oxygen saturation
Inspiratory fraction

PERSONAL HISTORY:

A. NOT PATHOLOGY
Socioeconomic Aspect :
1) lifestyle
a) High
b) Low
c) Medium

Residences and previous trips: to where ?

a) 10 days ago ___________________________________
b) 20 days ago_____________________________________
c) 1 month ago_____________________________________
d) 2 month ago_____________________________________
e) 1 years ago _____________________________________

Habits and customs:

a) Drugs
b) Smoke
c) Alcohol
d) Diet

Immunizations vaccine :
a) Hepatitis A
b) Hepatitis B
c) Hepatitis C
d) Influenza
e) Cholera

f) Rubeolla
g) Tetano and Diphtheria
h) Yellow fever
i) Papiloma Virus
j) other

Grandmother

Aunts

Grandfather

Uncler
Mother
Diabetes
Arterial
Hipertension
Cncer

Father

Sister

Brother

Dislipidemia
Coronary
Heart
Disease
Asthma
Epilepsy
Stroke
Obesity
Arthritis
Liver disease
Lung disease
Early death

B. PATHOLOGICAL
Previous Illnesses:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Y

N
Endocrinology
Type I Diabetes (Insulin dependant)
Type II Diabetes (Non-Insulin dependant)
Hyperthyroid
Hypothyroid
Goiter
Graves Disease
Neurological

Seizures
Epilepsy
Skin
Dermatitis
Rashes
Open sores
Psoriasis
Hematology
Blood clots from an injury or accident
Anemia
DVT (Deep Vein Thrombosis/Active Thrombophlebitis in legs)
Thrombocytopenia low platelets; bleeding problems

Iron supplements
Hemophilia
OB/GYN
Hormone replacement
Birth Control Pill/Patch
Irregular periods
Difficulty in conceiving

Gastrointestinal
GERD

Heartburn
Stomach (peptic ulcer)
Duodenal ulcer
Constipation
Diarrhea
Vomiting
Colitis
Irritable Bowel Syndrome
Crohns Disease
Gallbladder Disease
Gallstones (Cholelithiasis)
Inflammation/infection of gallbladder (Cholecystitis)
Respiratory
Asthma
Chronic Bronchitis
Sleep Apnea

COPD (Chronic Obstructive Pulmonary Disease)

Emphysema
Cardiovascular
Heart Attack (Myocardial Infarction)
Angina
Palpitations
High Blood Pressure (Hypertension)
Stroke (CVS)
Mini-Stroke (TIA)
Chest Pain

Heaviness in chest
Congestive heart failure
Peripheral vascular disease
High cholesterol
Infectious Disease
Hepatitis A
Hepatitis B
Hepatitis C
HIV Positive
Liver Disease
Genital-Urinary
Recurrent urinary infection
Kidney stones
Kidney disease
Renal/Kidney failure (dialysis)

Gout
Stress incontinence
Musculoskeletal
Arthritis
Back pain
Migraine headaches (describe): ____________________________
Pain in weight bearing joints
Psychological
Depression: Medication: _____________________________________

Bi-Polar Disorder
Anxiety
Suicide attempt
Anorexia
Bulimia
Cancer
Lung
Breast
Prostate
Colon
Lymphoma
Other:____________________________________________________
Accidents and sequelae:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Surgical:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________