University of the East

Ramon Magsaysay Memorial Medical Center, Inc.

# 64 Barangay Doña Imelda, Aurora Boulevard Quezon City 1113

DEPARTMENT OF MEDICINE
Tel: 715-08-05, 715-08-61 Loc. 262

RECORDING THE MEDICAL HISTORY

Format of the History Report (in the order of recording):

1. Patient Profile
2. Source and Reliability
3. Chief Complaint
4. History of the Present Illness
5. Past Health Maintenance History
6. Family History
7. Review of System

The Patient Profile

Purpose:
1. To discover what stimuli in the patient’s environment may be contributing to his illness.
2. To determine factors that may significantly influence diagnostic or therapeutic program for the
patient (ex. Financial resources).
3. To discover some information that may give important clue as to the cause of the patient’s
illness.

 The patient profile reveals the individual as a whole… his personality, his mental make-up and
his reaction to his environment and his illness.

Information to be included in the patient profile

1. Life History
a. Name h. Education
b. Sex i. Socioeconomic status of the family
c. Age and birth date j. Family composition and his/her place in the family
d. Place of residence k. Living environment – community, neighborhood,
e. Birthplace/ place of origin basic facilities
f. Race l. Hobbies and interests
g. Religion

2. Marital Status
- History, compatibility, adjustment

3. Occupation and Employment History

a. Nature of present and previous work
b. Presence of occupational hazards
c. Adjustment to working situations

4. Financial Status

5. Personality type and reaction to environment

- High Strung, chronic worrier, easy going, etc.
 6. Habits and Description of average day
a. Dietary and eating habits d. Use of tobacco (expressed in number of pack years)
b. Sleeping habits e. Alcohol intake
c. Exercise f. Caffeine and drug intake (substance abuse)

7. Current medications, if any

- Dose, frequency and duration of intake

The Chief Complaint

 Main reason for seeking consult
 Serves as a guide to the more detailed history

Guidelines in recording the Chief Complaint:

1. It is limited to a brief statement.
2. It is restricted to a single symptom or two at most.
3. It uses the patient’s own words as nearly as possible.
4. It refers to a concrete complaint (symptom).
(Not vague phrases such as kidney trouble or heat trouble)
5. It includes the duration of symptom.
6. It avoids the use of diagnostic terms or diseases.

History of the Present Illness

4 Basic Components:
1. Restatement of the chief complaint with elaboration in greater detail.
2. A history of the present problem from the time of onset.
3. A full description of the current status of the patient.
4. A summary of all significant positive and negative information.

 Note: It is preferable to use a separate paragraph for each chronological period and in that
paragraph analyze all symptoms completely and note positive and negative information closely
related to the symptoms describe. All other significant positives and negatives should be
summarized separately in the last paragraph (4th component of the HPI).

 Day of admission or consultation should be the reference date (period) of the onset and
progression or appearance of other symptoms. It could be several minutes, few hours/several
hours, days weeks, months, or years prior to consultation or admission day.

Technique of History Taking of the Present Illness – essentially a four-phase activity

Phase 1.
Obtain an account of the symptoms as the patient experiences them without introducing any bias
with direct questions. The patient should be encouraged to talk freely about his complaints with the use
of open ended neutral questions. These questions should help the patient recall the date his problem first
appeared.
Ex. Can you tell me when and how your problem started?
Tell me about your problem
What other symptoms did you notice since you became ill?

Phase 2.
This phase should provide for a detailed analysis of the symptoms described by the patient
through direct and detailed analysis of the symptom in its chronologic order and nalyze it (refer to the
topic on outline of symptom analysis).

Phase 3.
 This phase should test the diagnostic possibilities suggested by the data elicited during the first
two phases. The interviewer specifically inquires about other symptoms or events that normally form
part of the usual history of the suspected problem/s.

Phase 4.
The technique in the first three phases may fail to reveal all symptoms of importance to the
present problem, especially if they are remote in time and apparently not related to the present problem.
Some symptoms may be elicited only during the review of systems. Therefore the fourth phase should
provide for analysis of symptoms that were first revealed during the review of systems.

Excerpt from the Sample Patient Record

A. The patient enters with complaint of sporadic vomiting of bright red blood during the last
3 hours associated with midepigastric pain.
B. Three years prior to admission patient first noticed mid upper abdominal burning pain
after eating. The pain increased in frequency becoming daily with occasional nighttime
awakening with similar discomfort. Pain was exacerbated by highly seasoned foods. There were
no other food intolerances. There was no associated symptom of nausea, hematemesis, or
melena. He sought medical attention and was treated with antacids and diet restriction. His
symptoms subsided in few weeks and he remained well until…
Six months ago he had recurrence of the midepigastric pain with associated black tarry
stools and weakness he was hospitalized at _______ and upper GI series showed an ulcer. He
was also told he had mild anemia. He was managed conservatively with antacids, diet and
sedation during a one week hospitalization. His symptoms subsided and he was discharged
asymptomatic with home medications consisting of antacids for one month.
C. One week PTA, the patient noted occasional mild hunger pain which was relieved by
food intake. Two days prior to admission he noted increasing frequency and intensity of
midepigastric burning pain for which he took self-prescribe Maalox which afforded little relief.
Three hours prior to admission he suddenly vomited bright red blood three times estimated to
amount ½ to 1 cup for each episode at intervals of 30 minutes to one hour with the last episode
occurring about 15 minutes before arriving at the ER. He denies melena at this time but he feels
weak and a little giddy on standing up.
D. He denies history of liver disease, jaundice, or symptoms of a bleeding tendency. He
denies alcohol or aspirin ingestion. He occasionally smoked cigarettes. He has been under a lot
of stress at work lately. He denies any history of weakness or easy fatigue or shortness of breath
with exertion before the vomiting episode. He denies weight loss.

 From the sample patient record above, note that:

o Section A is an elaboration of the chief complaint that supplies greater detail
o Section B deals with the history of the present illness from the time of onset with detailed
description of the symptoms.
o Section C is a full description of the current status of the problem.
o Section D is a summary of all significant positive and negative information.

SYMPTOM ANALYSIS
It is important to use a standard method of analyzing a symptom. One basic outline for analyzing
symptoms:
1. Onset
a. Date of onset
b. Manner of onset (gradual or sudden)
c. Precipitating and predispoising factors related to onset
2. Characteristic
a. Character (quantity, quality, consistency, appearance)
b. Location and radiation (pain, cardiac murmur)
c. Intensity or severity
d. Timing (continuous or intermittent, duration of each, temporal relationship to other
events)
e. Aggravating and relieving factors
 f. Associated symptoms
3. Course since onset
a. Incidence
i. Single acute attack
ii. Recurrent acute attack
iii. Daily occurrences
b. Effect of therapy
c. Progress

The Six Point Check List for HPI

By Benjamin Policarpio, MD

The HPI if elicited thoroughly and accurately will have a predictive diagnostic value of 85% or
even more. How may one be confident that he has adequately accomplished the HPI?
This is done by going through the checklist of six items: 1. Components, 2. Sequence, 3.
Temporal relationships, 4. Analysis of Symptoms, 5. “Time holes”, and 6. ROS, by asking yourself…

1. Do I have all the components? (signs and symptoms)

2. Do I have the correct sequence? (the sequence of components has a telling influence on the
diagnosis)
3. Do I have the correct temporal relationships between the problems and S/S? This means not
only sequence but how the signs and symptoms overlap each other within the time frame of
present illness. This is valuable in the finer point of differential diagnosis since a
combination of two or more symptoms of an illness (syndrome) will have many diagnostic
possibilities.
4. Have I done an analysis of symptoms of all the components?
5. Are there “time holes” in my HPI; meaning, are there segments of time in the course of
illness which I am not clear about the behavior of a component (gone, better, worse). All
components must be accounted for within the time line of the illness.
6. Have I done a thorough review of systems? This is to cover the other components of the HPI
not elicited in the interview, or other significant but unrelated problems that have to be
looked into and addressed therapeutically.

It is very obvious that all the imaginable problems related to the thoroughness, accuracy, and
dependability of the HPI are covered by these.

The Past Health Maintenance History

1. Childhood diseases 5. Hospitalizations
2. Allergies 6. Major illnesses
3. Surgeries 7. Accidents
4. Immunizations 8. Pregnancies and deliveries, any abnormality

The Family History

1. Present status of parents and siblings – age, health status of each, cause of death, and age at
death, if any
2. Similar illness or symptom in the family
3. Common diseases with hereditary tendency – Diabetes Mellitus, hypertension,
cardiovascular disease, allergies, cerebrovascular disease, mental illness

The Review of Systems

 Systematic review of symptomatology by organ system
  To be certain that one has not missed other symptoms of the present illness not covered or
overlooked in the HPI
 Intended also to detect symptoms of other disease other than that covered in the HPI

The Temporal Profile Diagram

 Follows after the Review of Systems (before the record of the Physical Examination)
 The Temporal Profile of the HPI is a representative diagram of the different components as they
occur within the time frame or course of the present illness and to what extent they overlap each
other during the period
The height of the symptom curve from the baseline will reflect the severity of the same.
Max The shape, slope of the symptom curve will also depict the behavior of a symptom or
sign over the cause of the illness, from the onset to consult or admission.

The legend will be representing 2 or no more than 3 major symptoms of the illness, with
appropriate lines or colors, on the left side, below the diagram.

INTENSITY OF The “clinical horizon” (CH) and the time lines coincide (are one and the same) with each
SYMPTOMS other. A symptom curve that rises above it signifies its appearance or presence. Once it
touches the CH or time tine, it depicts its absence or relief or disappearance at that
particular point in time.

0 Onset Admission

TIME FRAME
(hours, days, weeks, months, as the case may be)

Legend:
------------- Symptom A
Symptom B
Symptom C

Guidelines:
1. As much as possible it is best to have the minimum number of symptom line (one or two or at
most three) to represent the temporal profile of several symptoms.
A temporal profile diagram of the HPI which is cluttered defeats its very purpose ie to show at a
glance the relationship of all the components during the course of the illness.
2. Should several symptoms have similar temporal profile, use only one symptom line to represent
all of them.
3. The graphic symptom line can be color coded or represented by symbols such as , ,
--------- or *****
4. Should there be more than one problem or illness in the HPI, each problem/illness should be
represented by its own separate corresponding schematic diagram/temporal profile.

 The height, shape, slope and sharpness of the symptom curve will serve to depict the symptom’s
severity, acuteness, and tempo over the time frame where it occurs. Some examples:

Gradual onset. Progressively worsening.

Acute onset. Unrelenting course up to admission.

Intermittent (alternately occurring and ceasing)

 Continuous. Remittent.

Acute episodes. Remittent + periodic

Recurrent (total episode repeats itself at various intervals of time—hours or days.

Eg afternoon fever every 2 or 3 days.

Periodic – Episode occurs in cluster of time in periods of days or weeks or months

with symptom-free period longer than the symptomatic period.

Gradual onset. Continuous. Waxing and waning.

 This is any example of a three component illness occurring within the given time frame of seven
days. Any symptom curve touching the baseline ‘O’ or “clinical horizon” will be interpreted as
absent. Note that the symptom lines are curves, NOT sharp angles.
Max

INTENSITY OF
SYMPTOMS

0 6 5 4 3 2 1 A

TIME LINE OR CLINICAL HORIZON

Legend:

Jaundice
RUQ Pain
Fever

Paracetamol
A Admission

In this example, one will see that the sequence of the components is: RUQ pain followed by jaundice
and lastly by fever. The temporal profile also clearly shows how the signs and symptoms overlap each
other. There are many conditions characterized by these 3 components, but the underlying cause or
diagnosis changes with the change in the sequence of these components. More importantly, the temporal
relationships of the three components may furnish further information as to its specific diagnosis/cause,
when there are two or more possibilities, or with the same components and sequence. The steepness and
shape of the curves show that the RUQ pain occurred on and off to progressively worsen to 2 days PTA
until admission. Jaundice is noted four days PTA, and progressively worsens or deepens on the day of
admission. Fever was noted 2 days PTA lasting until admission. In the account of the HPI, further
description or elaboration can be given to the RUQ pain as colicky and severe, while fever may be
described as remittent, septic with swings between 38 to 40C or continuous.

The temporal profile offers a view of the “forest” (course of illness) as well as the “individual trees”
(components). The relationship of all components over the course of the illness is a great and
inestimable value for correct diagnosis.

Sample of Review of System Record

REVIEW OF SYSTEMS: (Write N if findings are negative/normal. Place a check if findings are
positive/abnormal then describe in space provided)
Begin with a general question eg “Do you have any trouble with your eyes?”, then ask specific questions
like “Has your vision changed?, etc”

GENERAL DESCRIPTION
Fever___Fatigue___Sweating___Weight loss___Weakness___
SKIN
Color___Texture___Itching___Rashes___Changes in hair/nails___
EYES
Visual Impairment___Redness___Tearing___Pain___
Double vision___Discharge___Trauma___
EARS
Hearing loss___Otalgia___Discharge___Tinnitus___
NOSE, THROAT, MOUTH
Nasal obstruction___Discharge___Abnormal olfaction/Anosmia___
Epsitaxis___Frequent colds/cough___Dysphagia___Odynophagia___
Change in voice___Neck mass___Toothache___
Dental caries___Gum bleeding___Ulceration___Congenital deformities___
RESPIRATORY
Cough/sputum___Difficulty of breathing___Wheezing (asthma)___
PTB exposure___Hemoptysis___
CARDIOVASCULAR
Palpitation___Syncope___Chest pain___Edema____Hypertension___
Orthopnea___Dyspnea
GASTROINTESTINAL
Dysphagia___Nausea___Vomiting___Appetite___Abdominal pain___
Melena___Jaundice___Bleeding___Indigestion____Heartburn___
Hematemesis___Fatty food intolerance___Stool frequency/character___
Hemorrhoids___Abdominal distention___Hernia___
URINARY
Pain___Volume___Retention___Bleeding___Stream___Polyuria___
Nocturia___Stones___Infection___Hesitancy___Urgency___Change in
color___Frequency___Dribbling___
GENITOREPRODUCTIVE
Male: Discharge___Pain___Libido___Sexual difficulties___
Female: Menarche___LMP___PMP___Menses: regular___duration___Amt___
Abnormal vaginal bleeding___Discharge___Dysmenorrhea/pelvic pain___
Post-coital bleeding__Contraceptive use___No. of pregnancies___
Complications___Live births____Heaviest baby___lbs.___PID___
Menopause age___Postmenopausal bleeding___
BREAST
Nipples___Lump___Pain___Discharge___
EXTREMITIES
Cyanosis___Clubbing___Edema___Varicosity___Ulcers___Claudication___
HEMATOPOIETIC SYSTEM
Excessive bleeding/bruising___Anemia___Pica___
NERVOUS SYSTEM
Headache___Tremor___Fainting spells___Seizures___Dizzines/vertigo___
Head trauma___Sensory perversions___
MUSCULOSKELETAL
Joint stiffness___Pain___Swelling___Muscle weakness___
ENDOCRINE SYSTEM
Heat/cold intolerance___Thyroid problems___Neck surgery/irradiation___
DM indicators___
PSYCHIATRIC
Mood swings___Behavioral changes___Anxiety___Depression___

References:
1. A physiological approach to the clinical examination, 3rd edition by Judge and Zuideema
2. Physical diagnosis by Elliot Hochstein and Al Rubin, Copyright 1964 by McGraw Hill.