History taking

Posted: July 17, 2010 by gerardloh in Medicine

History taking for Medicine
by Dr. Ng Kean Seng, MD, CSMU (UKRAINE) 2010

1. Age/Race/sex

Eg: 56/Malay/M

2. K/C/O ( Known case of@ co morbid)

Eg:

A. DM 20 years, Currently on T Metformin 500mg bd 2) HPT Currently on? Follow up where?

B. Previously healthy

C. Refer from KK Taman Ehsan, differential diagnosis disease?

3. C/C ( Chief complaints)

A. State the MAJOR Problem in one or two of the patient’s own words. Do not use medical terminology.

For example: Chest pain for 2 hours. Ask: “Encik, saya hendak tanya, kenapa encik datang ke hospital?” “Boleh saya tahu apa yang menggangu encik” This generally tells you how to gear up your question for the ‘History of presenting illnesse’.

B. Follow sequence based on time flow:

For example : fever 2/7, cough 5/7, headache 2/52

4. HOPI (HISTORY OF PRESENTING ILLNESS):

Describe the onset, nature and course of each symptom. Important because it directs you to the system you would be concentrating during your physical examination.

A- Describe the presenting complain as completely as possible.

For example: Patient complains of pain. ‘SOCRATES drill’ S – site O – onset C – character R – radiation A – associated symptoms T – timing E – exacerbating/alleviating factor S – severity (X/10)

B- Eliminate causes that could present in a similar manner.

Keep a differential diagnosis in your mind and ask questions accordingly. Include relevant positive and relevant negative Example: Chest pain Ask symptoms associated with

  • Myocardial Infarction
  • Pericarditis
  • Aortic dissection
  • Pulmonary embolism
  • Oesophageal spasm

Example :

Relevant positive
– Typical history, pain history
– ECG – hyperacute T waves
– Cardiac enzyme – troponin

Relevant negative

– X fever
– X cough
– X risk of DVT
– X related with food / lying flat

C- Thirdly, ask about the any risk factors and relevant past history for the diagnoses you might have in mind at this point.

For example: Positive family history for ischemic heart disease, Past medical history of angina or myocardial infarction, Hypercholesterolaemia etc.

5. PMHx (PAST MEDICAL HISTORY):

  • Further Elaborate K/C/O
  • Write in chronological order.
  • Include important negatives

Example: Patient with chest pain you should ask about previous Ml, angina, HT or DM and record whether these are present or absent.

Remember to ask about following diseases!

Respiratory: Tuberculosis, asthma, bronchitis
CVS: Hypertension, Ischemic heart disease, Rheumatic fever,
CNS: Epilepsy, Cerebral-vascular event
Liver: Jaundice Diabetes

‘MJ THREADS’

– M yocardial infarction
–J aundice

– T uberculosis
–H ypertension
– R heumatoid Arthritis
– E pilepsy
– A sthma
– D iabetes Mellitus
– S troke

6. PSHx ( PAST SURGICAL HISTORY)

  • What operation is done and date of operation
  • GA ( General Anesthesia) / SA ( Sacral Anesthesia)

If there is local anesthesia you should ask why choose local in the last operation? Maybe there is complication of GA

7. MENSTRUAL HISTORY

  • Regular/ Irregular?
  • ? Pad (1 pad = 100ml)
  • Hx of flooding? Blood clot?
  • Intermenstrual bleeding
  • Menorrhagia? Dysmenorrhea?
  • OCP (oral Contraceptive pills)? Hormone pills?

8. FAMILY HISTORY

  • Includes any family member with similar conditions; parents health,
  • If diseased then cause of and age at death
  • Health of siblings
  • Any children and their health

Example : Hypertension , hyperlipidemia, TB, DM ,Ca à Draw family tree à inherited disease / Ca

9. SOCIAL HISTORY

Living conditions of the patient, for example: whether living alone or not, independent or has special helper to manage care at home, income etc.

Habits that are proven risk factors for certain disease.

a. Smoking
Unit= PACK YEARS
A pack-year is smoking 20 cigarettes a day for one year.
If someone has smoked ten cigarettes a day for six years they would have a three pack-year history. Someone who has smoked forty cigarettes daily for twenty years has a forty pack-year history.

Number of Pack Years = (Packs smoked per day) x (years as a smoker)

or

Number of pack years = (number of cigarettes smoked per day x number of years smoked)/20 (1 pack has 20 cigarettes).

Eg:: a patient who has smoked 15 cigarettes a day for 40 years has a (15×40)/20 = 30 pack year smoking history.

b. Alcohol intake specifying ‘present or previous intake’, ‘daily intake’, ‘intake over years’.

Alcoholism screening test TWEAK
Have u increased Tolerance of alcohol? 2pts
Have close friends or relatives Worried or complained about your drinking in the past year? 2pts
Do you sometimes take a drink in the morning when you first get up? (Eye opener) 1pt
Has a friend or family member ever told you about things you said or did while you were drinking that you could not remember? (Amnesia) 1pt
Do you sometimes feel the need to c(K)ut down on your drinking? 1pt

> 3 points = alcoholism

c. If appropriate also ask about illicit drug use, sexual history, occupation and pets.

recent travel (chest pain might be the hidden pulmonary embolism due to deep venous thrombosis developed during long flights).

10. Allergy Hx

  • Ask for any allergies that the patient might have.
  • Drugs (penicilin), food (seafood, shellfish), environment (pollen, fur)
  • Traditional medicine ( can promote renal and liver failure)

11. Provisional Diagnosis or Impression

= (most likely diagnosis)

Most likely diagnoses In patients with multiple pathology make a problem list so the key issues are seen immediately

12. DD (Differential Diagnosis)

  • at least 2-3 similar diseases
  • to rule out

eg: Myocardial infarction ? To rule out PE /pericarditis

13. Plan

  • List the investigations required.
  • When a result is already available, for example of an ECG, record it.
  • If uncertain about an investigation or treatment, precede with a “?” and discuss with a more senior member of staff

E.g. 1) Fluids – 1 pint D5% over 24h
2) Investigation: FBC/ RP/ LFT/ CXR/ECG
3) Medication: IV Ranitidine 50Mg
4) Other – refer Palliative – VS monitor every 4 hours – I/O chart – To D/W Mr. Ng for further man

14. Management

Record any immediate management instigated

Clerked By:

Presenting Summary:

  • 56/Malay/Male
  • K/C/O
  • Presented with the CC of
  • Relevant HOPI
  • @ this stage my provisional diagnosis is
  • With the differential diagnosis of

Example: 56 years old Malay gentlemen, refered from ED, with known case of DM for 20 years currently on Metformin 500mg bd, HPT for 10 years, patient is not sure of the name of the medication for HPT. Currently patient is on follow up at KK Taman Ehsan for HPT.

Patient complaints of acute central pain which radiate to the left arm and neck, associated with dyspnea and palpitation, pain last more than 1 hour and intensity is 8/10 according to the patient. GTN doesn’t help.

Patient smokes 10 packs per year. Patient’s father passed away on 2003 due to AMI. Patient has past medical history of MI for 2 times, which is on 2005 and 2007.

At this stage my provisional diagnosis is Acute Myocardium Infraction with ddx of Pulmonary Embolism and Pericarditis.

15. O/E (GENERAL/ON EXAMINATION)

On admission

 Physical appearance e.g. alert, drowsy, unconscious

 Skin color: pink, cyanosis, pallor, jaundice

  • Ankle edema
  • Clubbing
  • Bp
  • Pulse
  • Temp
  • RR

16. Systemic Review:

 CVS: Peripheral Pulse: Good volume, regular rhythm

Heart: DRNM

  • Respi: Lungs: Clear, A/E equal
  • Abdomen/GU System: P/A:
  • CNS: Cranial Nerves

Peripheral Nerves

  • PR: Inspection/ palpable mass/ color of stool

If it is revision of patient:

  • I/O: 1500cc/1520cc
  • -20cc
  • RT / tapping : Volume/ color- 70cc (Greenish)
  • Urine Output: 50-75cc/ hr

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