Internal Medicine History-Taking

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Questions and Answers

What is the abbreviation for 'Past medical history'?

  • PMH (correct)
  • PHM
  • PH
  • 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?

<p>Albinism (C)</p>
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What is the primary focus of the 'Review of System' in a patient's subjective information?

<p>Verbal report of patient complaints (A)</p>
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What is the term for 'chest pain' related to cardiovascular diseases?

<p>Angina pectoris (B)</p>
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What is the term for 'esophagogastric diseases' that can cause chest pain?

<p>Gastroesophageal reflux disease (B)</p>
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What percentage of diagnoses can be made based on history alone?

<p>83% (D)</p>
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What is the primary purpose of the 'Assessment' section in a patient's SOAP notes?

<p>To select diagnosis and treatment plans (C)</p>
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What is the primary reason for recording the chief complaint in the patient's own words?

<p>To facilitate communication with the patient (B)</p>
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What is the purpose of asking about OPQRSTA/symptom in the history of present illness?

<p>To amplify the chief complaint and gather more information about the symptom (A)</p>
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What should be documented when evaluating the reliability of the source of history?

<p>The quality of the information provided (D)</p>
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What is the significance of recording the date and time of history?

<p>It provides a timeline for the patient's symptoms (D)</p>
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What is the primary purpose of obtaining a comprehensive adult health history?

<p>To determine the etiology of the patient's symptoms (D)</p>
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What is the significance of identifying the source of history?

<p>It helps to assess the type of information provided and potential biases (C)</p>
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What is the purpose of recording the patient's thought and feelings in the history of present illness?

<p>To provide a more complete picture of the patient's symptoms (C)</p>
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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

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

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