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Complete Medical History Taking Guidelines (USCE)

Complete Medical History Taking Guidelines (USCE)

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Page 1 of 4 Paragraphs of History Patient Profile • Name: 3. Respiratory 4. Urogenital 5. Neurological 6. Musculoskeletal 7. Others (in next page) • Age/DOB: • Occupation: Past Medical History • Religion: • Hospitalization? • Blood Group: • Date of Admit: • Mode of admission: (ER/OPD) • Co – Morbid: Drug History • Drug allergies (ex: penicillin) • NSAIDs • Steroid • Marital Status: • Residence: • Frequency • J – Jaundice • A – Anemia • Antiplatelets (Aspirin) • Anticoagulants (Heparin and warfarin) • Oral hypoglycemic drugs (OHD) • M – Myocardial Infarction • Oral contraceptive drugs (OCP) • T – tuberculosis • H – Hypertension • R – Rheumatic fever Travel History • E – Epilepsy Chief/Presenting complains Note: (A good PC should have following qualities) • Should be problems that brought patient to hospital • No medical terminologies • Should be objective statement • Patient’s own language • If more than 1 PCs must be written in chronological order • Duration History of presenting illness (→) Note: (in next section) Associated symptoms (system involved) Note: (in next page) • A ...
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Tags: usmle step2 Step1 amc AMC1 AMC2 amcusce plab plab1 plab2 plabusce dha amboss firstAid usce usceguidelines completeusce history historyguidelines historytaking completehistory FamilyHistory travelhistory socialhistory MedicalHistory surgicalhistory symptoms Sign systems systeminquiry patienthistory

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