OLFU College of Medicine Class 2015

Medicine I
Dr. Cortez
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 Religion o Seventh-Day Adventist not advised to undergo gastroscopy o Jehovahs witness not allowed to have blood transfusion Place of Birth o Samar high prevalence of schistosomiasis 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 feels ex. palpitation o Sign physical finding ex. tachycardia o diagnostic procedure ex. colonoscopy o treatment ex. peritoneal dialysis Not necessary the INITIAL SYMPTOM felt by the patient The HPI will not always start with the Chief Complaint 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 line ex. Fever Chills Appropriate questions should be used like What brings you to the hospital? Tell me about your problem. Record the chief complaint as nearly as the patients own words as possible (but translate it into English) ex. nahihirapan huminga difficulty of breathing III. History of Present Illness Most important part of medical history Written in narrative form Should be chronological

Lecture 1: History Taking June 20, 2012

A. Onset of the Illness o Start from the onset of the first symptom up to the time of consultation/admission in the hospital o Manner of onset is it gradual or sudden? o Date of reference as to the onset of each symptom o Number of minutes, hours, days, weeks, months, years, etc before the date of consultation/admission B.All symptoms felt by the patient (chronological sequence) o Symptoms which appeared before the chief complaint o Symptoms which appeared with the chief complaint Constitutional symptoms such as weakness (All people who are sick experience panghihina) o Symptoms which appeared after the chief complaint o Note for the absence of symptoms that may have diagnostic significance No associated cough, sore throat (so you are able to exclude RTI as a cause of the fever) No other associated symptoms C. Analysis of Each Symptom Detailed description of each symptom o Precipitating/Palliative Factors o Quality o Region/Radiation o Severity o Timing 1. Precipitating/Palliative Factors Symptom: Epigastric pain Was it precipitated by hunger? Was it relieved by food intake? By antacid? Emotional stress (anger, anxiety, excitement) and physical stress (strenuous exercise) Food/Diet (epigastric pain after a fatty meal) Environment (exposure to dust) Quality Pain sharp, throbbing/pulsating (headache), pressing (chest pain), colicky, crampy (abdominal pain), gnawing, dull Region/Location, Radiation Ask the patient to point out the specific location of the pain and to where it radiates Ex. chest pain radiating to the left shoulder (myocardial infarction) Severity/Intensity of Symptom and its Progression Usually assessed by how it affects the patients activities of daily living, lifestyle, personal and interpersonal relationships Mild, moderate or severe? Decresendo, crescendo Improving, worsening or unchanged? Report in pain scale of 1-10

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OLFU College of Medicine Class 2015

Medicine I
Dr. Cortez
5. Timing Onset Duration Periodicity/Frequency

Lecture 1: History Taking June 20, 2012

5.

The patient was apparently well until two hours PTA, the patient suddenly developed severe anterior chest pain radiating to the shoulder and jaw, palliated by sublingual nitroglycerin, but after 30 minutes, it recurred and it was also compressing and radiating to the back. Associated with difficulty of breathing. Most Common Symptoms 1. Pain Chest, abdomen, headache, back, lower back, joint pain 2.

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 of breathing, which was not relieved by nebulization by Salbutamol.

upper

Fever Documented (by thermometer) or undocumented (by touch)? Low-grade or high-grade? Character: Intermittent Remittent Continuous dengue fever Biphasic leptospirosis Stepladder typhoid fever Vomiting Projectile (due to ICP) or nonprojectile? Frequency (How many episodes per day?) 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 two days PTA for about 3-4 episodes per day. Vomitus was described as composed of undigested food with blood streak, amounting to one half cup per bout.

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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

Clarification Categorize symptoms to corresponding medical term o I feel weak Paralysis weakness of more muscle group Malaise generalized body weakness Myalgia muscle pain Dizziness Unstable gait disequilibrium Whirling sensation vertigo Swelling Inflammation (with pain) Edema

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Loose Bowel Movement (LBM) Frequency (How many day?) Character of Stool Watery Mucoid Blood-streaked Color Odor Amount

times

per

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.

D. Medication/Consultation Medication o Dosage o Generic name o Duration (How long taken?) o Effects of Treatment Consultation o Indicate what laboratory procedures were done (Ask in layman terms) o Results (temporary relief, slight relief) E. Outcome o Results after intervention o Is there improvement? Complete or partial? F. Recurrence o Did the disease recur? G. Other accompanying Symptoms

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OLFU College of Medicine Class 2015

Medicine I
Dr. Cortez
H. Ending Statement o What symptom made you decide to seek consultation? Because of loss of consciousness, patient was brought to the hospital. o o Important data may be very helpful to the diagnosis Maybe a positive/negative sign Patient attended the party and ate shrimps and oysters six hours before the onset of LBM. (To imply that the shrimps and oysters MAYBE the cause of LBM) No other person who attended the said party developed similar complaints. (Rules out the possibility 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 Diseases o Specific o Measles, mumps, chicken pox o Indicate the date and if there are complications B. Immunizations o Date, type of vaccine received o Avoid using the term complete immunization o If patient cannot remember, use the term unrecalled immunizations C. Accidents/Injuries o Date, type, sequelae In 1990, during a car accident, the patient sustained a lacerated wound on the anterior left leg which was sutured D. Surgeries o Type, date, complications place/hospital, results, A. Educational Attainment o Grade school graduate o High school graduate o College graduate B. Occupation o Previous/present occupation o Duration C. Marital Status o What age did the patient get married? o Health condition of spouse and children D. Living Condition o Housing, ventilation, source of water, waste disposal, toilet, environment E. Economic Condition o Who is the one working? How much is the monthly salary? F. Habits o Diet o Coffee, tea, softdrinks o Sleeping pattern o Hobbies o Alcohol intake amount, type, frequency o Smoking kind, when did the patient start to smoke? How many pack-years? Number of packs per day times number of years he is smoking = number of pack-years o Use of prohibited drugs o Exercise o Food preference o Travel Menstrual and OB History A. Menstrual o Menarche age, duration, symptoms, menstrual flow o Subsequent menstruation interval, duration, amount of flow, symptoms, LMP, PMP o Menopause age, symptoms

Lecture 1: History Taking June 20, 2012

H. Psychiatric o Violence o Drug overdose/abuse o Suicidal attempts V. Family History A. Health Status of Parent & Siblings o Age and current health status of parents and siblings o Illness o If deceased, age at time of death and cause of death (or symptoms before the relative died) Father died at 50 due to chest pain Mother still living at 49 with hypertension, diabetes and presently with recurrent joint pain B. Heredofamilial disease o HPN, DM, cancer, heart disease, psychiatric illness C. Any member of the family with similar illness o Mother died of renal failure. Older sister has polycystic kidney disease V. Personal and Social History

E. Allergies o Specify allergens (dust, smoke, perfume, dust, drugs, food) o Allergic reactions (signs and symptoms) F. Hospitalizations or Other Illnesses not related o Date o Place of Admission o Signs and symptoms o Laboratory procedures and results o Medicine o Diagnosis o Discharge o Home medications and instructions o Follow-up G. Blood Transfusions o Indications o How many units transferred? o Blood components o Reaction

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OLFU College of Medicine Class 2015

Medicine I
Dr. Cortez
B. OB History o Gravidity number of pregnancies o Parity number of outcomes o OB Score FPAL Full-term Pre-term (less than 28 weeks) Abortion (less than 20 weeks) Living Ex. G3P3 3-0-0-3 o Describe each pregnancy as to manner of delivery Spontaneous Normal Forcep extraction C. Gynecological o Sexually-transmitted disease o Hydatiform mole, ovarian cyst, polycystic ovary, vaginal discharge, dyspareunia o 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.

Lecture 1: History Taking June 20, 2012

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