1 - Clinical - History - 29

Clinical History
Dr. Rodney Martnez
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)
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)
Presenting complaint (PC) or Chief complain (CC)

This is the patient's chief symptom(s) in their own words and should be no more than a single sentence. The motive of consultation usually
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 with exactly how and when it started, how the problem has progressed over time, and what impact it has had on the patient in terms of their general physical health, psychology, social, and working lives.
History of the presenting complaint (HPC) or History of the present illness (HPI)
For each symptom, determine:

The exact nature of the symptom. The onset:
What is the exact manner in which it comes and goes?
Change over time:
Periodicity and frequency: Relieving factors:
Is it improving or The date it began. deteriorating? How it began (e.g. suddenly, gradually over how long?) Exacerbating factors: What makes the symptom If longstanding, why is the worse? patient seeking help now? What makes the symptom Is the symptom constant or better? intermittent? How long does it last each Associated symptoms. time?
For pain, determine:

Site (where is the pain worst ask the patient to point to the site with 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).
Systematic enquiry (SE)

After talking about the presenting complaint, you should perform a brief screen of the other bodily systems.
Change in the apetite Weight change

General symptoms
Malaise
Fever
Lethargy
Sputum
Chest pain
Haemoptisis
Respiratory symptoms
Wheeze
Shortness of breath
Cough
Shortness of breath on exertion

Chest pain Claudication
Cardiovascular symptoms
paroxysmal nocturnal dyspnoea
orthopnoea
Palpitations
ankle swelling
haematuria nocturia dysuria
Urinary frequency
impotence
polyuria
Genitourinary symptoms
menstrual problems
Neurological symptoms
Headaches weakness
tingling
dizziness
faints
Tremor
Black outs
Aches Locomotor symptoms Stiffness
Pains
Swelling
Lumps
Itch
Skin symptoms
Bumps
Rashes
Ulcers
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
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.
Allergies
This should be documented separately from the drug history due to its importance
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
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 week or concentrated into a smaller period
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
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.
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
Establish
Marital status. Sexual orientation. Occupation (or previous occupations if retired).
You should establish the exact nature of the job if it is uncleardoes it involve sitting at a desk, carrying heavy loads, travelling?
Does the patient use any walking aids (e.g. stick, frame scooter)? Does the patient receive any help dayto-day?
Who from? (e.g. family, friends, social services.) Who does the laundry, cleaning, cooking, and shopping?
Other people who live at the same address. 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 or adaptations in their house? (e.g. rails near the bath, stairlift etc).
Does the patient have relatives living nearby? 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?
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
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.
Key points
Drug history: remember polypharmacy and that patients may not remember all the treatments they take. Be aware that more drugs mean more side effects and less concordance so ask which are taken and why(older) people are often quite honest about why they omit tablets. Eye drops, sleeping pills, and laxatives are often regarded as non-medicines by patients, so be thorough and ask separately and avoid precipitating delirium due to acute withdrawal of benzodiazepines.
Key points
Social history: is exactly that, and should complement the functional history. Occupation (other than retired can be of value when faced with a new diagnosis of pulmonary fibrosis or bladder cancer and may give your patient a chance to sketch out more about their lives. Enquire about family don't assume that a relative may be able to undertake more help, as they may live far away; the patient may still have a spouse but be separated. Chat with patients about their daily lives understanding interests and pursuits can help distract an unwell patient, give hope for the future, and act as a spur for recovery and meaningful rehabilitation.

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Clinical History

Dr. Rodney Martnez

Standard (American version)

Standard (British version)

Presenting complaint (PC) or Chief complain (CC)

For each symptom, determine:

Change over time:

Periodicity and frequency: Relieving factors:

For pain, determine:

Systematic enquiry (SE)

Change in the apetite Weight change

Shortness of breath on exertion

paroxysmal nocturnal dyspnoea

haematuria nocturia dysuria

Aches Locomotor symptoms Stiffness

Past medical history (PMH)

Past medical history ask specifically about:

Drug history (DHx)

Family history (FHx)

Social history (SHx)

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