Medicine Lecture 1 - History Taking

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Medicine I Lecture 1: History TakingJune 20, 2012

OLFU College of Medicine Class 2015

Dr. Cortez

Ut In Omnibus Glorificetur Deus Page 1 of 4

History Taking General Data Chief Complaint History of Present Illness or Interval History Past Medical History Family History Personal and Social History Review of Systems

I. General Data*written in paragraph form

Name Age Civil Status Sex Occupation Nationality Religiono Seventh-Day Adventist not advised to

undergo gastroscopyo Jehovahs witness not allowed to have

blood transfusion Place of Birth

o Samar high prevalence ofschistosomiasis

Present Residence Number of Admissions in the hospital Date of Admission

II. Chief Complaint Principal reason for seeking consult or

admission It can be a

o Symptom what the patient feelsex. palpitation

o Sign physical findingex. tachycardia

o diagnostic procedureex. colonoscopy

o treatmentex. peritoneal dialysis

Not necessary the INITIAL SYMPTOM felt by thepatient

The HPI will not always start with the ChiefComplaint

Can be 1 or 2 complaints Do not use diagnosis or names of diseases Use only words/phrases, not complete sentences Duration of fever may be mentioned

ex. fever of two weeks duration If there is more than one complaint, write each

complaint in a separate lineex. Fever

Chills Appropriate questions should be used like What

brings you to the hospital? Tell me about yourproblem.

Record the chief complaint as nearly as thepatients own words as possible (but translate itinto English)ex. nahihirapan huminga difficulty ofbreathing

III. History of Present Illness Most important part of medical history Written in narrative form Should be chronological

A. Onset of the Illnesso Start from the onset of the first

symptom up to the time of

consultation/admission in the hospitalo Manner of onset is it gradual or

sudden?o Date of reference as to the onset of each

symptomo Number of minutes, hours, days, weeks,

months, years, etc before the date ofconsultation/admission

B.All symptoms felt by the patient (chronologicalsequence)

o Symptoms which appeared before thechief complaint

o Symptoms which appeared with the chiefcomplaint

Constitutional symptoms such asweakness (All people who aresick experience panghihina)

o Symptoms which appeared after thechief complaint

o Note for the absence of symptoms thatmay have diagnostic significance

No associated cough, sore throat(so you are able to exclude RTIas a cause of the fever)

No other associated symptomsC. Analysis of Each Symptom

Detailed description of each symptomo Precipitating/Palliative Factorso Qualityo Region/Radiationo Severityo Timing

1. Precipitating/Palliative Factors Symptom: Epigastric painWas it precipitated by hunger? Was itrelieved by food intake? By antacid? Emotional stress (anger, anxiety,

excitement) and physical stress(strenuous exercise)

Food/Diet (epigastric pain after afatty meal)

Environment (exposure to dust)2. Quality

Pain sharp, throbbing/pulsating(headache), pressing (chest pain),colicky, crampy (abdominal pain),gnawing, dull

3. Region/Location, Radiation Ask the patient to point out the

specific location of the pain and towhere it radiatesEx. chest pain radiating to the leftshoulder (myocardial infarction)

4. Severity/Intensity of Symptom and itsProgression

Usually assessed by how it affectsthe patients activities of dailyliving, lifestyle, personal andinterpersonal relationships

Mild, moderate or severe? Decresendo, crescendo Improving, worsening or unchanged? Report in pain scale of 1-10


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Dr. Cortez


5. Timing Onset Duration Periodicity/Frequency

The patient was apparently well until two hours PTA, thepatient suddenly developed severe anterior chest painradiating to the shoulder and jaw, palliated bysublingual nitroglycerin, but after 30 minutes, itrecurred and it was also compressing and radiating tothe back. Associated with difficulty of breathing.

ClarificationCategorize symptoms to corresponding medical term

o I feel weak Paralysis weakness of more muscle

group Malaise generalized body weakness

Myalgia muscle pain

o Dizziness Unstable gait disequilibrium Whirling sensation vertigo

o Swelling Inflammation (with pain) Edema

D. Medication/ConsultationMedication

o Dosageo Generic nameo Duration (How long taken?)o Effects of Treatment

Consultationo Indicate what laboratory procedures were done

(Ask in layman terms)o Results (temporary relief, slight relief)

E. Outcomeo Results after interventiono Is there improvement? Complete or partial?

F. Recurrenceo Did the disease recur?

G. Other accompanying Symptoms

Most Common Symptoms1. Pain

Chest, abdomen, headache, upperback, lower back, joint pain

2. Fever Documented (by thermometer) or

undocumented (by touch)? Low-grade or high-grade? Character:

Intermittent Remittent Continuous dengue fever Biphasic leptospirosis Stepladder typhoid fever

3. Vomiting Projectile (due to ICP) or non-

projectile?

Frequency (How many episodes perday?) Timing (Is it near meals? How many

hours after food intake?) Composition of vomitus

(Digested/undigested food Color (bilous, blood-streaked,

coffeeground) Amount (How many cups per bout?)

Patient developed non-projectile vomiting twodays PTA for about 3-4 episodes per day.Vomitus was described as composed ofundigested food with blood streak, amountingto one half cup per bout.

4. Loose Bowel Movement (LBM) Frequency (How many times per

day?) Character of Stool

Watery Mucoid Blood-streaked

Color Odor Amount

Patient developed LBM after eating oysters.Freqency was more than 5 times a day. Stool

described as watery, whitish, foul-smelling,amounting to 1 cup per bout.

5. Dyspnea Activity that produces it (strenuous

activity) Precipitating factor Relieving factors (rest, nebulization

by Salbutamol) Other manifestations

Easy fatigability Orthopnea PND (left ventricular HPN) Platypnea

A few hours PTA, patient developed successive,non-productive cough, then difficulty ofbreathing, which was not relieved bynebulization by Salbutamol.

6. Cough Onset (sudden or gradual) Duration Nature

dry, moist hoarse,hacking, whooping,

bubbling Productive/nonproductive Sputum (color, amount, odor) Pattern

Occasional Regular Paroxysmal precipitated by activities/

exercise/ weather change/pollutant exposure


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Dr. Cortez


H. Ending Statemento What symptom made you decide to seek

consultation?

Because of loss of consciousness, patient wasbrought to the hospital.

o Important data may be very helpful to thediagnosis

o Maybe a positive/negative signPatient attended the party and ate shrimps andoysters six hours before the onset of LBM. (Toimply that the shrimps and oysters MAYBE thecause of LBM)

No other person who attended the said partydeveloped similar complaints. (Rules out thepossibility of food poisoning)

Interval History If there are previous admissions related to the

HPI Obtain previous records and summarize the

pertinent info Used for chronic conditions with numerous

previous admissions for the same illness

IV. Past Medical History

A. Childhood Diseaseso Specifico Measles, mumps, chicken poxo Indicate the date and if there are complications

B. Immunizationso Date, type of vaccine receivedo Avoid using the term complete immunizationo If patient cannot remember, use the term

unrecalled immunizations

C. Accidents/Injurieso Date, type, sequelae

In 1990, during a car accident, the patientsustained a lacerated wound on the anterior leftleg which was sutured

D. Surgeries

o Type, date, place/hospital, results,complicationsE. Allergies

o Specify allergens (dust, smoke, perfume, dust,drugs, food)

o Allergic reactions (signs and symptoms)F. Hospitalizations or Other Illnesses not related

o Dateo Place of Admissiono Signs and symptomso Laboratory procedures and resultso Medicineo Diagnosiso Dischargeo Home medications and instructionso Follow-up

G. Blood Transfusionso Indicationso How many units transferred?o Blood componentso Reaction

H. Psychiatrico Violenceo Drug overdose/abuseo Suicidal attempts

V. Family History

A. Health Status of Parent & Siblingso Age and current health status of parents and

siblingso Illnesso If deceased, age at time of death and cause of

death (or symptoms before the relative died)Father died at 50 due to chest painMother still living at 49 with hypertension,diabetes and presently with recurrent joint pain

B. Heredofamilial diseaseo HPN, DM, cancer, heart disease, psychiatric

illness

C. Any member of the family with similar illnesso Mother died of renal failure. Older sister has

polycystic kidney disease

V. Personal and Social History

A. Educational Attainmento Grade school graduateo High school graduateo College graduate

B. Occupationo Previous/present occupationo Duration

C. Marital Statuso What age did the patient get married?o Health condition of spouse and children

D. Living Conditiono Housing, ventilation, source of water, waste

disposal, toilet, environment

E. Economic Conditiono Who is the one working? How much is the

monthly salary?

F. Habitso Dieto Coffee, tea, softdrinkso Sleeping patterno Hobbieso Alcohol intake amount, type, frequencyo Smoking kind, when did the patient start to

smoke? How many pack-years?Number of packs per day times number of yearshe is smoking = number of pack-years

o Use of prohibited drugso Exerciseo Food preferenceo Travel

Menstrual and OB HistoryA. Menstrual

o Menarche age, duration, symptoms, menstrualflow

o Subsequent menstruation interval, duration,amount of flow, symptoms, LMP, PMP

o Menopause age, symptoms


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Dr. Cortez


B. OB Historyo Gravidity number of pregnancieso Parity number of outcomeso OB Score FPAL

Full-term Pre-term (less than 28 weeks) Abortion (less than 20 weeks) Living

Ex. G3P3 3-0-0-3o Describe each pregnancy as to manner of

delivery Spontaneous Normal Forcep extraction

C. Gynecologicalo Sexually-transmitted diseaseo Hydatiform mole, ovarian cyst, polycystic ovary,vaginal discharge, dyspareuniao Family planning (calendar rhythm)o Birth Control (Contraceptives, IUDs, pills)

VI. Review of Systems Comprehensive review of all complaints

referable to each body system Used to search for symptoms that may have

escaped the clinician How is your health in general? Symptoms written in the HPI may NOT be

repeatedly mentioned in the ROS If symptoms present are related to the present

illness, put them in the HPI and not in the ROS.

Medicine Lecture 1 - History Taking

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