1 - clinical_history - 29

8/12/2019 1 - Clinical_history - 29

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Clinical History

Dr. Rodney Martnez


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Standard (American version)

Name: Address: Phone Number: Marital Status: Age: Gender: Chief complaint

History of present illness;

Health issues: Past medical history: Social history Family history: Review of systems (physical examination)


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Standard (British version)

Presenting complaint (PC)

History of presenting complaint (HPC)

Systematic enquiry (SE)

Past medical history (PMH)

Allergies

Drug history (DHx)

Alcohol

Smoking Family history (FHx)

Social history (SHx)


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Presenting complaint (PC)

or

Chief complain (CC)

This is the patient's chief symptom(s) in theirown words and should be no more than a

single sentence.

The motive of consultation usually


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History of the presenting complaint

(HPC)

orHistory of the present illness (HPI)

Here, you ask about and document the details of

the presenting complaint. By the end of this, you should have a clear idea

about the nature of the problem along withexactly how and when it started, how theproblem has progressed over time, and whatimpact it has had on the patient in terms of theirgeneral physical health, psychology, social, andworking lives.


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For each symptom, determine:

The exact nature of thesymptom.

The onset: The date it began.

How it began (e.g. suddenly,gradually over how long?)

If longstanding, why is thepatient seeking help now?

Periodicity and frequency:

Is the symptom constant orintermittent?

How long does it last eachtime?

What is the exact manner inwhich it comes and goes?

Change over time: Is it improving or

deteriorating?

Exacerbating factors: What makes the symptom

worse?

Relieving factors:

What makes the symptombetter?

Associated symptoms.


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For pain, determine:

Site (where is the pain worst ask the patient to point to the sitewith one finger).

Radiation (does the pain move anywhere else?).

Character (i.e. dull, aching, stabbing, burning etc.).

Severity (scored out of 10, with 10 as the worst pain imaginable).

Mode and rate of onset (how did it come on over how long?).

Duration.

Frequency.

Exacerbating factors.

Relieving factors. Associated symptoms (e.g. nausea, dyspepsia, shortness of breath).


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Systematic enquiry (SE)

After talking about the presenting complaint,

you should perform a brief screen of the other

bodily systems.


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Generalsymptoms

Changein the

apetite

Weightchange

LethargyFever

Malaise


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Respiratorysymptoms

Sputum

Haemoptisis

Shortness ofbreath

Cough

Wheeze

Chest pain


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Cardiovascularsymptoms

Shortness ofbreath onexertion

Claudication

orthopnoea

ankleswelling

Palpitations

paroxysmalnocturnaldyspnoea

Chest pain


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Genito-

urinarysymptoms

polyuria

Urinary

frequency

nocturia

haematuria

dysuria

impotence

menstrual

problems


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Neurological symptoms

Headaches weakness tingling dizziness faints Tremor Black outs


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Aches Pains

Stiffness Swelling

Locomotorsymptoms


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Skinsymptoms

Lumps

Bumps

UlcersRashes

Itch


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Past medical history (PMH)

Here, you should obtain detailed information

about past illness and surgical procedures.

For each condition, ask:

When was it diagnosed?

How was it diagnosed?

How has it been treated?

For operations, ask about any previous

anaesthetic problems


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Past medical history ask specifically

about:

Diabetes.

Rheumatic fever.

Jaundice.

Hypercholesterolaemia.

Hypertension.

Angina.

Myocardial infarction.

Stroke or TIA.

Asthma.

TB.

Epilepsy.

Anaesthetic problems.

Blood transfusions.


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Allergies

This should be documented separately from

the drug history due to its importance


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Drug history (DHx)

Here, you should list all the medication the

patient is taking, including the dose and

frequency of each prescription.

You should make a special note of any drugs

that have been started or stopped recently


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Alcohol

You should attempt to quantify, as accurately

as you can, the amount of alcohol consumed

per week and also establish if the

consumption is spread evenly over the weekor concentrated into a smaller period


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Smoking

Attempt to quantify the habit in pack-years. 1

pack-year is 20 cigarettes per day for one year.

(e.g. 40/day for 1 year = 2 pack-years; 10/day

for 2 years = 1 pack-year


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Family history (FHx)

The FHx details:

The make up of the current family, including

the age and gender of parents, siblings,

children, and extended family as relevant.

The health of the family.


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Social history (SHx)

This is your chance to document the details of

the patient's personal life which are relevant

to the working diagnosis, the patient's general

well-being and recovery/convalescence.

It will help to understand the impact of the

illness on the patient's functional status


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Establish

Marital status.

Sexual orientation.

Occupation (or previous occupations ifretired). You should establish the exact nature of

the job if it is uncleardoes it involvesitting at a desk, carrying heavy loads,travelling?

Other people who live at the sameaddress.

The type of accommodation (e.g.house, flat and on what floor).

Does the patient own their

accommodation or rent it? Are there any stairs? How many?

Does the patient have any aids oradaptations in their house? (e.g. railsnear the bath, stairlift etc).

Does the patient use any walking aids(e.g. stick, frame scooter)?

Does the patient receive any help day-to-day? Who from? (e.g. family, friends, social

services.)

Who does the laundry, cleaning, cooking,

and shopping?

Does the patient have relatives livingnearby?

What hobbies does the patient have?

Does the patient own any pets?

Has the patient been abroad recently

or spent any time abroad in the past? Does the patient drive?


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Key points

Learn to listen:it can be tempting to ask lots

of questions to obtain every fact in the history,

particularly if you are rushed.

It often saves you time, as other key

information may emerge straight away, and

you can better focus the history


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Key points

Problem lists: patients with chronic illness or

multiple diagnoses may have more than one

strand to their acute presentation.

Consider breaking the history of the

presenting complaint down into a problem list

e.g. (1) worsening heart failure; (2) continence

problems; (3) diarrhoea; (4) falls.

This can often reveal key interactions

between diagnoses you might not have

thought about.


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Key points

Drug history: remember polypharmacy and thatpatients may not remember all the treatments theytake.

Be aware that more drugs mean more side effects and

less concordance so ask which are taken andwhy(older) people are often quite honest about whythey omit tablets.

Eye drops, sleeping pills, and laxatives are often

regarded as non-medicines by patients, so be thoroughand ask separately and avoid precipitating delirium dueto acute withdrawal of benzodiazepines.


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Key points

Social history: is exactly that, and should complement thefunctional history.

Occupation (other than retired can be of value when facedwith a new diagnosis of pulmonary fibrosis or bladdercancer and may give your patient a chance to sketch outmore about their lives.

Enquire about family don't assume that a relative may beable to undertake more help, as they may live far away; thepatient may still have a spouse but be separated.

Chat with patients about their daily lives understandinginterests and pursuits can help distract an unwell patient,give hope for the future, and act as a spur for recovery andmeaningful rehabilitation.

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