16 Questions
What is the abbreviation for 'Past medical history'?
PMH
What does 'QD' stand for in a medication prescription?
Quaque die
What is the term for 'brain electric disturbance' in the context of medical history?
Fits
Which of the following is an example of a familial disease?
Albinism
What is the primary focus of the 'Review of System' in a patient's subjective information?
Verbal report of patient complaints
What is the term for 'chest pain' related to cardiovascular diseases?
Angina pectoris
What is the term for 'esophagogastric diseases' that can cause chest pain?
Gastroesophageal reflux disease
What percentage of diagnoses can be made based on history alone?
83%
What is the primary purpose of the 'Assessment' section in a patient's SOAP notes?
To select diagnosis and treatment plans
What is the primary reason for recording the chief complaint in the patient's own words?
To facilitate communication with the patient
What is the purpose of asking about OPQRSTA/symptom in the history of present illness?
To amplify the chief complaint and gather more information about the symptom
What should be documented when evaluating the reliability of the source of history?
The quality of the information provided
What is the significance of recording the date and time of history?
It provides a timeline for the patient's symptoms
What is the primary purpose of obtaining a comprehensive adult health history?
To determine the etiology of the patient's symptoms
What is the significance of identifying the source of history?
It helps to assess the type of information provided and potential biases
What is the purpose of recording the patient's thought and feelings in the history of present illness?
To provide a more complete picture of the patient's symptoms
Study Notes
Internal Medicine 1 - History-Taking
Diagnosis
- First step in determining etiology: obtaining accurate history
- 83% of diagnoses can be made based on history alone
- 9% of diagnoses changed after investigations
- 8% of diagnoses changed after physical examination
Comprehensive Adult Health History
Identifying Data
- Personal details: date and time of history, source of history, and reliability
- Source of history: patient, family member, friend, letter of referral, medical record
- Reliability of source: documented and judged by quality of info provided
Chief Complaint (C/C)
- Main reason for patient seeking physician help
- Recorded in patient's own words: symptom + time
- Principles of recording C/C:
- Select most important symptom
- Use patient's own words > medical term
- Duration, frequency, interval of main symptom
- Use simple phrase
History of Present Illness (HPI)
- Ask OPQRSTA/symptom
- Amplifies C/C, relevant associated symptoms, how symptom developed
- Recording sequence: include patient thoughts and feelings
- Medications, allergies, habits (smoking and alcohol)
- Aggravating/releasing factors
Past Medical History (H/O, PMH)
- Childhood/adult illness, medical, allergies
- Past illness: IHD/Heart Attack/DM/Asthma/HT/RHD/TB/Jaundice/Fits
- Operation, injuries, vaccine = time/place/type
- Blood transfusion (mention quality and reaction), Psychiatric, health maintenance (dental)
Drugs History (DH)
- Use generic name or trade name with dosage, duration in brackets
- Eg. Ranitidine 150 mg BD PO
- QD: quaque die = For every day
- Eg. Q2H = quaque 2 hora
- Qh = quaque hora
- QID = quarter in die
Personal and Social History
- Tobacco, alcohol, Ob/Gyn History (menstrual history, sexual history)
- Healthy alcohol associated with less IHD and Ischemic CVA
- Unhealthy alcohol associated with CVA, liver cirrhosis, CPNS dysfunction, Myopathies, Cardiomyopathy
Family History
- Familial disease: cancer, IHD, DM, hepatitis B & C, schizophrenia, albinism, asthma
- Infectious: TB, Leoprosy
- Epidemics: Cholera, typhoid
Systemic Review (SR), Review of System (ROS)
- Verbal report: no significant finding on SR = you did it
- Write pt note = record SR
- Common symptoms & 3 or 4 common disorders
Chest Diagnostics
PART 1: NORMAL SYMPTOMS RELATED TO CHEST
- Chest pain etiology:
- Musculoskeletal of chest
- Cardiovascular diseases
- Pulmonary diseases
- Psychosocial pain
- Mediastinum diseases
- Others: esophagogastric diseases, hepatobiliary diseases
This quiz covers the importance of history-taking in internal medicine, including the accuracy of diagnoses made solely from patient history and the impact of investigations and physical examinations on diagnosis.
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