Clinical History. Dr. Rodney Martínez

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1 Clinical History Dr. Rodney Martínez 1

2 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) 2

3 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) 3

4 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 4

5 History of the presenting complaint (HPC) or History of the present illness (HPI) Here, you ask about and document the details of the presenting complaint. 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. 5

6 For each symptom, determine: The exact nature of the What is the exact manner in symptom. which it comes and goes? The onset: Change over time: The date it began. Is it improving or deteriorating? How it began (e.g. suddenly, graduallyâ over how long?) Exacerbating factors: If longstanding, why is the What makes the symptom patient seeking help now? worse? Periodicity and frequency: Relieving factors: Is the symptom constant or What makes the symptom intermittent? better? How long does it last each Associated symptoms. time? 6

7 Systematic enquiry (SE) After talking about the presenting complaint, you should perform a brief screen of the other bodily systems. 7

8 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 8

9 Past medical history ask specifically about: Diabetes. Stroke or TIA. Rheumatic fever. Asthma. Jaundice. TB. Hypercholesterolaemi Epilepsy. a. Anaesthetic Hypertension. problems. Angina. Blood transfusions. Myocardial infarction. 9

10 Allergies This should be documented separately from the drug history due to its importance 10

11 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 11

12 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 12

13 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) 13

14 Family history (FHx) It 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. 14

15 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 15

16 Establish Marital status. The type of accommodation Sexual orientation. (e.g. house, flat and on Occupation (or previous what floor). occupations if retired). Does the patient own their You should establish the accommodation or rent it? exact nature of the job if it is Are there any stairs? How unclear does it involve many? sitting at a desk, carrying heavy loads, travelling? Does the patient have any aids or adaptations in their Other people who live at house? (e.g. rails near the the same address. bath, stairlift etc). 16

17 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 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? 17

18 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. Doing this will not only frustrate and offend your patient (because you clearly don't listen), but will also risk you missing important facts. Instead, learn to stay quietand listen in detail to the history of the presenting complaint which may only be 3-4 minutes, but gives your patient a chance to be heard 18

19 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. 19

20 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. 20

21 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. 21

Clinical History. Dr. Rodney Martínez

Clinical History. Dr. Rodney Martínez Clinical History Dr. Rodney Martínez Standard (American version) Name: Address: Phone Number: Marital Status: Age: Gender: Chief complaint History of present illness; Health issues: Past medical history:

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