Clinical History

Professor Niazy Abu Farsakh Jordan University of Science and Technology

Diagnosis in Medicine
- Clinical history - Physical Examination - Investigations

Clinical history

Patients profile Chief complaint History of the present illness Systemic review Drug history History of allergy Past history Family history Socioeconomic history

Patients Profile
Name Age Sex Marital status Area of residence Education Occupation Setting of the interview: - Place - Time and date

Chief Complaint
Main symptom(s) or other abnormalities (may be a sign or lab abnormality) which brought the patient to medical attention and its duration.

History of the present illness

Includes details of the chief complaint - Mode of onset - Course and progression - Duration - Existence of precipitating or relieving factors - Development of other symptoms since onset of disease till the time of the interview in a chronological order and the relation of these symptoms to the chief complaint. - Mention other symptoms or relevant data related to the system affected if they are negative or positive.

Example
Chief complaint: Chest pain Present history: - Mode of onset: sudden, gradual, episodic-- Course: progressive, intermittent, decreasing--- Site - Radiation - Character - Severity - Duration - Frequency and periodicity - Special times of occurrence - Precipitating factors - Aggravating factors - Relieving factors Associated symptoms and their relation to pain Risk factors for ischemic heart disease as cigarette smoking, diabetes, hyperlipidemia

Chest pain

Patient was doing well till yesterday when he had sudden onset of central chest pain which started while he was walking uphill, relieved 10 minutes after rest, pain was severe, burning in nature, radiating to left shoulder and back, associated with sweating and dizziness. He had no SOB during the pain, and no palpitation. He has no history of diabetes or hypertension. He smokes 20 cigarettes/day. Has no family history of IHD.

Attacks of SOB

Patient with history of bronchial asthma for last 3 years with recurrent attacks, was doing well till today morning when he started to have sudden onset of SOB with wheezing and cough with production of tenacious sputum for last 6 hours, worsening with time in spite of using inhalers. he has no fever, no hemoptysis and no chest pain. He gave history of similar attacks over last 3 years, precipitated by URT infection, exposure to perfumes and dust with improvement on inhalers. He is relatively free between the attacks. No history of hospitalization before.

Systemic review
Inquiry about all symptoms of the various systems if they are positive or negative recently

General symptoms
- May be present in diseases of any system - Fever, general weakness, fatigue, malaise, anorexia, loss of weight

Cardiovascular symptoms
- Chest pain - Shortness of breath *orthopnea * paroxysmal nocturnal dyspnea - Palpitation - Ankle swelling - Syncopal attacks, fatigue - Intermittent claudication

Respiratory system
URT symptoms: sneezing, nasal discharge, epistaxis, nasal obstruction, sore throat, hoarseness of voice, stridor LRT symptoms: Chest pain Shortness of breath Cough and sputum Wheezing Hemoptysis

Gastrointestinal symptoms
Mouth ulcers Difficulty or pain with swallowing: dysphagia Nausea and vomiting Heartburn, regurgitation Abdominal pain Abdominal distension Disturbances in bowel motions: constipation or diarrhea Anal pain, discharge or itching Hematemesis, rectal bleeding (hematochezia) or melena.

Urinary symptoms
Renal pain Dysuria, Frequency of micturition: nocturnal
frequency

Disturbed stream of micturition Discoloration of urine Amount of urine: polyuria, oliguria, anuria

Musculoskeletal system
- Joint pain
Joint swelling Limitation of movements in various joints. Muscle pain and muscle wasting Bone pains Deformities

Dermatological symptoms
Skin rash Itching Pain Swellings Disturbance in pigmentation Bleeding into skin Disturbances in hair: hirsuitism, alopecia, hair fall Disturbances in nails

In males:

Genital tract symptoms

erectile dysfunction, disturbances in ejaculation, urethral discharge, sexual history

In females: - age of menarche / menopause

- regularity of menstruation - vaginal discharge, pruritis - amount of menstrual bleeding - menstrual pain - sexual history - obstetric history: number of pregnancies, number of abortions, number of deliveries, mode of delivery

Neurological symptoms
Disturbance in level of consciousness Headache Fits Special senses: hearing, taste, vision, smell Speech disturbances Disturbances in sleep Motor or sensory deficits, Disturbance in gait Sphincteric disturbances.

Endocrinological symptoms
Cold or heat intolerance, Excessive sweating Change in weight Polyuria, polydipsia General weakness and fatigue

Hematological symptoms
Symptoms of anemia: pallor, general weakness and easy fatigability , exertional dyspnea and palpitation Recurrent fevers Bleeding tendency

Psychiatric Symptoms
History of traumatizing events, anxiety, depression, obsession, fear of certain diseases, mental illnesses.

Important comment:
Any symptom found during enquiry for systemic review should be analyzed regarding its course, severity, frequency, duration, any relieving or precipitating factors, and medications received

Drug history
- Details of all recent drugs taken by the patient - Details of drugs taken in the past for long periods - Any reaction or side effects to drugs

History of allergy
- Any allergy to drugs, food, pollens, clothes - Type of reaction: itching, urticaria, skin rash, respiratory difficulty, eye symptoms.

Past history
- History - History past. - History - History - History - History - History - History - History - History of similar attacks in the past of diseases in the system involved in the of of of of of of of of hospitalization operations major non operative trauma. severe acute illnesses chronic illnesses blood transfusion vaccination recent travel

Family history
- History of similar diseases in family members - History of family diseases in the involved system - History of chronic illnesses in family members - History of major acute illnesses recently

Socioeconomic history
marital status and children level of education income living circumstances recent jobs hobbies cigarette smoking alcohol drinking drug abuse

Summary of clinical History

Includes: name, age, chief complaint and its duration, major associated positive symptoms and related data, major past or family diseases.

Differential diagnosis
Various possibilities for patient presentation arranged in an ordered way from the most likely diagnosis to the least likely one.

THANK YOU