Medical History Taking

Genital SR symptoms

(only when appropriate) vaginal discharge, itch, pelvic pain, pain during intercourse, pattern of periods, last normal menstrual period, genital rash or ulcers, penile discharge

Four things to do when first meeting the patient

1) Wash hands 2) Introduce self and explain purpose of interview 3) Give full name and role while offering handshake 4) Greet patient by full name and title, unless patient is a child, then use first name

Common duration/onset notations

3/52 = 3 weeks & 2/12 = 2 months

Hematological SR symptoms

Abnormal bruising, bleeding, lumps

Standard immunizations (same in AU and US)

All before 4yrs: tetanus, diphtheria, pertussis, hep B, haemophilus, pneumococcus, polio, meningococcus, measles, mumps, rubella, rotavirus, varicella. At 12-13yrs: HPV. At 50 yrs: tetanus and diphtheria are boosted. From 65 years: influenza vaccine (yearly) and pneumococcal (two injections five years apart).

How to obtain the History of Presenting Complaint or HPC

Always use open-ended questions initially, then ask closed questions to obtain more specific details. For specifics, use NILDOCAAFIAT, especially for red flags and risk factors.

Allergies and adverse drug reactions

Ask about medication allergies, other allergies, and problematic side effects. Record the cause as well as the type and severity of the reaction. No allergy is recorded as NKA (no known allergy) or NKDA (no known drug allergy).

Obtaining past surgical history

Ask about the operation, the method, the date, the reason, and the laterality (side of surgery)

Screening history

Ask if pt has had any screening tests, including pap smears, mammograms, fecal occult blood tests (FOBT), colonoscopy, or other screenings as indicated by risk in Hx.

How to obtain the presenting complaint(s)

Broad, open-ended questions. (e.g. How can I help you today?)

Menstrual history

Can be extensive, but at a minimum obtain when the last normal menstrual period (LNMP) started. Date and normalcy must be confirmed in order to rule out pregnancy. Also include the amount of bleeding, duration of the period and number of days of bleeding (e.g. 4/28). and whether they occur regularly or irregularly. Lastly, if applicable, ask about what method of contraception is used.

Cardiovascular SR symptoms

Chest pain, shortness of breath, palpitations, fainting, leg pain

Respiratory SR symptoms

Cough, sputum, wheeze, coughing up blood

Urinary SR symptoms

Difficulty passing urine: pain, stream, starting, stopping, dribbling

General SR symptoms

Fever, sweating, weight gain or loss, rash, skin changes

Obstetric notation

G: gravid - number of confirmed pregnancies P: para - number of viable (>20wks) births, with multiple pregnancies counted as one. Neonatal death is often recorded as a superscript after the P or as NND after the T M: miscarriages T: terminations (e.g. G5P3M1T1 NNDx1)

Example of appropriate greeting to patient

Good morning, Mr. Brown, my name is John Collins and I'm a first-year UQ medical student. I would like to have a chat with you about why you are in the hospital and record your medical history.

Social history

Important for determining possible predisposition to illness and for establishing management plans. Record age, race, religion, living arrangements, partner/family, education, occupation (current and past), community support (if relevant e.g. home help, respite care).

Endocrine SR symptoms

Increased sweating, hair loss, neck swelling

Family history (FHx)

Inquire about the health of first-degree relatives (parents, siblings, children) and sometimes second-degree relatives. Record the age and cause of death of deceased relatives and the age and current health of living relatives. May use diagrammatic form if genetic illness is suspected.

Basic demographics

John Collins DOB 19/10/1988 26, male, student May need to use hospital wrist ID or interpreter. Also, may need to inquire about religious or cultural issues.

Musculoskeletal SR symptoms

Muscle, joint, or bone pain or swelling, joint stiffness, dry mouth or eyes

NILDOCAAFIAT

Nature Intensity - out of 10 Location Duration Onset Contributing - cause Aggravating Alleviating Frequency Impact - effect on life Attribute - pt assumed cause Treatment - pt administered

Gastrointestinal SR symptoms

Nausea, vomiting, swallowing difficulty, abdominal pain, indigestion, constipation, diarrhea, rectal bleeding

Obstetric history

Obtain information about all pregnancies, not just live births, and include the duration, baby weight, and birthdays. Use GPMT notation.

Substance use

Obtain information about tobacco, alcohol, and recreational drug use.

Medication history

Obtain list of current medications. Record brand name, generic name, formulation (e.g. tabs, caps, inhaler, liquid), strength, dosage, frequency, and mode of administration. Also ask about OTC meds, oral contraceptives (OCPs) in females, supplements, issues with compliance to medication regimen, and previously stopped or changed medications and the reasons for discontinuation.

Sexual history

Obtain only if relevant to the consultation. Inquire about sexual activity, partners, length of relationships, STD screenings

Past medical history (PMH)

Past and present illnesses, conditions, and procedures recorded with a time reference, either how long (e.g. since 2005) or when diagnosed (e.g. Dx 2005). Try to record most recent illness first.

Pregnancy notation

Pregnancies are dated from the first day of the LNMP, but can also be based on ultrasound dating. It is written either as K32 or 32/40 for someone 32 weeks pregnant.

Documenting alcohol use

Quantify and convert to standard drinks, with one standard drink being 10g of alcohol. One light beer (3.5% alcohol) = 1 standard drink, one full strength beer (5% alcohol) = 1.5 standard drinks. Also record frequency (e.g. Alcohol - daily use - 1-2 standard drinks weekdays, 8-10 standard drinks weekends)

Lifestyle

Record diet, exercise, hobbies, and pets.

Documenting tobacco use

Recorded in pack years, which is cigs/day/year, with 20 cigs per pack. Examples of a pack year pack can be that the pt has smoked a pack a day for a year, 5 cigs a day for 4 years, or 1 cig a day for 20 years. Also record when smoking occured (e.g. 5 pack years from age 17 to 27, nil since)

Mode of presentation

Refers to how pt was transported to the medical facility. (e.g. BIBA/brought in by ambulance or brought in by husband who is present for this consultation)

Neurological SR symptoms

Seizures, fainting, headache, visual changes, weakness, numbness

Immunization history

Should always be documented in primary care. Ask about when they were administered and if there were any reactions.

Dermatological SR symptoms

Skin, hair, or nail changes

Psychiatric SR symptoms

Sleep, appetite, weight change, mood change, anxiety

Presenting complaint(s) or PC

The reason the pt has presented to the doctor at that time. Can be a specific symptom or a list of symptoms. Record in lay terms rather than medical terms and be sure to establish a time frame. (e.g. Chest pain - 24 hours)

Conclusion

To conclude every consultation, ask the pt if they have anything else they'd like to talk about. Then progress to examination.

How to record time

Use 24hr format (e.g. 17.30)

Systems Review (SR) or Review of Symptoms (ROS)

Used to identify symptoms that may have been missed in earlier history. Record all positive responses to questions, and only pertinent negative responses.

How to record negative findings

no headache, headache - nil, ^0headache