Internal Medicine History-Taking

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Questions and Answers

What is the abbreviation for 'Past medical history'?

PMH (correct)

PHM

PHH

What does 'QD' stand for in a medication prescription?

Quaque die (correct)

Quaque hora

Quarter in die

Quaque 2 hora

What is the term for 'brain electric disturbance' in the context of medical history?

Seizures

Epilepsy

Convulsions

Fits (correct)

Which of the following is an example of a familial disease?

Albinism Signup and view all the answers

What is the primary focus of the 'Review of System' in a patient's subjective information?

Verbal report of patient complaints Signup and view all the answers

What is the term for 'chest pain' related to cardiovascular diseases?

Angina pectoris Signup and view all the answers

What is the term for 'esophagogastric diseases' that can cause chest pain?

Gastroesophageal reflux disease Signup and view all the answers

What percentage of diagnoses can be made based on history alone?

83% Signup and view all the answers

What is the primary purpose of the 'Assessment' section in a patient's SOAP notes?

To select diagnosis and treatment plans Signup and view all the answers

What is the primary reason for recording the chief complaint in the patient's own words?

To facilitate communication with the patient Signup and view all the answers

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 Signup and view all the answers

What should be documented when evaluating the reliability of the source of history?

The quality of the information provided Signup and view all the answers

What is the significance of recording the date and time of history?

It provides a timeline for the patient's symptoms Signup and view all the answers

What is the primary purpose of obtaining a comprehensive adult health history?

To determine the etiology of the patient's symptoms Signup and view all the answers

What is the significance of identifying the source of history?

It helps to assess the type of information provided and potential biases Signup and view all the answers

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 Signup and view all the answers

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

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

Chest pain etiology:
- Musculoskeletal of chest
- Cardiovascular diseases
- Pulmonary diseases
- Psychosocial pain
- Mediastinum diseases
- Others: esophagogastric diseases, hepatobiliary diseases

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Description

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.