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: 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
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. 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.
For each symptom, determine: The exact nature of the symptom. The onset: The date it began. How it began (e.g. suddenly, gradually over how long?) If longstanding, why is the patient seeking help now? Periodicity and frequency: Is the symptom constant or intermittent? How long does it last each time? What is the exact manner in which it comes and goes? Change over time: Is it improving or deteriorating? Exacerbating factors: What makes the symptom worse? Relieving factors: What makes the symptom better? Associated symptoms.
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 Malaise General symptoms Weight change Fever Lethargy
Sputum Chest pain Haemoptisis Respiratory symptoms Wheeze Shortness of breath Cough
Shortness of breath on exertion Chest pain Claudication paroxysmal nocturnal dyspnoea Cardiovascular symptoms orthopnoea Palpitations ankle swelling
nocturia haematuria dysuria Urinary frequency impotence polyuria Genitourinary symptoms menstrual problems
Neurological symptoms Headaches weakness tingling dizziness faints Tremor Black outs
Aches Pains Locomotor symptoms Stiffness 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 unclearâ does it involve sitting at a desk, carrying heavy loads, travelling? 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 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? 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.