Medical History PDF

INTRODUCTION IN CLINICAL PRACTISE Prof.dr.Gordana Kamceva Mihailova FMN, UGD – Shtip, 2022/23 “Medicine is to be learned only by experience; it is not an inheritance; it cannot be revealed. Learn to see, learn to hear, learn to feel, learn to smell, and know that by practice alone can you become...

INTRODUCTION IN CLINICAL PRACTISE Prof.dr.Gordana Kamceva Mihailova FMN, UGD – Shtip, 2022/23 “Medicine is to be learned only by experience; it is not an inheritance; it cannot be revealed. Learn to see, learn to hear, learn to feel, learn to smell, and know that by practice alone can you become expert. Medicine is learned by the bedside and not in the classroom. See, and then reason and compare and control. But see first.” — Sir William Osier (1849-1919) Professor of Medicine, Oxford, UK PROFESSIONAL SCIENTIFIC DOCUMENT FORENSIC MEDICAL DOCUMENT MEDICAL HISTORY • In 1816, Rene Theophile Hyaeinthe Laennec invented the stethoscope — the single instrument that came to symbolize the bedside physician and the weapon used by the clinicians for almost last two centuries. • The term patient is derived from the Latin word 'patiens’, or 'to suffer’. A ‘patient’ is one who feels sick physically or mentally and consults doctor for relief of his ailments. In clinical medicine, patients hold the key position. Naturally, it is the task of the physician that he should do the needful for the recovery of the patient. • To relieve the sufferings of the patients, a doctor should ascertain at first, the nature of illness from which the patient is suffering from. In other words, the doctor has to diagnose the existing disease. • Physical diagnosis makes the bridge between the study of disease and the management of illness. Clinical diagnosis is an artistic science, based on three kinds of medical informations : (I) Communication with the patient (i.e., the history taking), (II) Physical examination, and (III) Investigations THE HISTORY OF THE DISEASE REPRESENTS a basic document that refers to all relevant data about the patient and the disease, which are an integral part of documenting the health status of the patient, especially important during the first visit for medical treatment, but also during all possible subsequent visits. The process of solving the patient's health problem has several levels. – First, data is collected from the previously mentioned clinical skills : • communication with the patient (i.e., the history taking), • physical examination, and • basic diagnostic tests and their critical evaluation. – Then follows the phase of classifying the previously collected data according to logical order and importance, separating the normal from the pathognomonic facts. – In the next phase, on the basis of the knowledge that has been obtained previously, the so-called hypothetical or working diagnosis when it is often necessary to check all data collected so far, or to repeat or conduct additional diagnostic tests and consultations. – Finally, several possibilities are considered (differential diagnosis), that is, several hypotheses, based on facts, knowledge, experience. At the same time, it should always be kept in mind that patients may have several diseases at the same time, which may have a mutual influence. INSTRUCTIONS FOR HISTORY TAKING AND PHYSICAL EXAMINATION OF A PATIENT HISTORY TAKING (Anamnesis) • Anamnesis is the first and most important stage in establishing a correct diagnosis. Basically, it is about data obtained from the patient, but synthesized and filtered by the doctor, and it refers to his health. The data is obtained through:  Autoanamnesis  Heteroanamnesis  Sometimes for numerous reasons such as: o the patient's state of consciousness (unconsciousness, disorientation), o anxiety, o state of panic, o the intellectual level of the patient, o some handicaps (deafness, muteness, etc.),  the doctor is unable to obtain reliable data. Then he will have to get the data completely, or in addition, from the closest ones in the family, the work environment, the witnesses of the event, the companions and/or other officials. In these cases, the caution of the doctor must be increased towards the obtained data. HISTORY TAKING ANAMNESIS • Understanding the patient’s experience of illness by taking a history is central to the practice of all branches of medicine. • The process requires patience, care and understanding to yield the key information leading to correct diagnosis and treatment. • In a perfect situation a calm, articulate patient would clearly describe the sequence and nature of their symptoms in the order of their occurrence, understanding and answering supplementary questions where required to add detail and certainty. • At no point can history taking (medical events that have already taken place) be considered as ‘wastage’ of time; in most cases, the diagnosis can be made with history alone. • History taking is an art, which a doctor should learn over years by repeated practice. Using different styles of question • Begin with open questions such as ‘How can I help you today?’ or ‘What has brought you along to see me today?’ • Listen actively and encourage the patient to talk by looking interested and making encouraging comments, such as ‘Tell me a bit more.’ • Always give the impression that you have plenty of time. Allow patients to tell their story in their own words, ideally without interruption. • You may occasionally need to interject to guide the patient gently back to describing the symptoms, as anxious patients commonly focus on relating the events or the reactions and opinions of others surrounding an episode of illness rather than what they were feeling. Using different styles of question The way you ask a question is important: • Open questions are general invitations to talk that avoid anticipating particular answers: ‘What was the first thing you noticed when you became ill?’ Can you tell me more about that?’ • Closed questions seek specific information and are used for clarification: ‘Have you had a cough today?’ ‘Did you notice any blood in your bowel motions?’ Both types of question have their place, and normally clinicians move gradually from open to closed questions as the interview progresses. • Being empathic helps your relationship with patients and improves their health outcomes. • Try to see the problem from their point of view and convey that to them in your questions. Consider a young teacher who has recently had facial surgery to remove a benign tumour from her upper jaw. Her wound has healed but she has a drooping lower eyelid and facial swelling. She returns to work. Imagine how you would feel in this situation. • Express empathy through questions that show you can relate to your patient’s experience. • While examining the patient, an experienced doctor not only ‘sees’ but also ‘uses all of his senses’ and gradually develops the keen ‘power of observation’ which is known as ‘clinical eye’ or ‘clinical acumen’. • To learn this, one has to go to the bedside of the patients for years together, to make keen observations, to examine them thoroughly and sympathetically, and to try to ‘associate’ different observations and findings. • Gradually the person develops the inherent ‘knowledge of correlation’ with the help of clinical eye. • This is why, Hippocrates commented: ‘A great part, I believe, of the art of medicine is the ability to observe. Leave nothing, combine contradictory observations and allow yourself enough time'. • An experienced clinician not only hears but listens, not only sees but observes, and not only touches but feels. ONE, WHO HAS SHARP CLINICAL EYE, BECOMES SUCCESSFUL IN LIFE IN THE LONG RUN. • Start the examination with coming into contact with the patient. - Greet the patient – e.g. Good morning, Mr. Kamcev! - Shake his hand. - Put your hand on his hand. - Introduce yourself. - Ask …. This attitude enables a doctor or a student to establish a proper relation with the patient, which makes further cooperation easier. - Ask the patient about the reason for his visit; what are his complaints? - Let him talk about his complaints using his own words as long as necessary. - Listen carefully and make notes. - Do not demonstrate irritation if the history is unclear or if you think that some information is not important or contributory. If you interrupt too fast, you may miss an important syndrome, if you keep listening you will know which symptoms are important for your patient. - Let the patient talk for about 2 minutes. . Patients talk about their complaints in many ways. Sometimes they do not make any distinction between important and irrelevant symptoms and tend to cover the crucial theme by exposing inessential details. • That is why you should take over the conversation – ask more detailed questions, interrupt patient to avoid too complicated, long stories. • If you think that you obtained the crucial information, stop the conversation politely but firmly. Parts of History Taking/Recording It consists of the following parts: 1. Name, age, sex, father’s name, marital status, full address, occupation, socio-economic status (general data) 2. Chief complaints. 3. History of present illness. 4. Past history of illness. 5. Treatment (drug) history. 6. Family history. 7. Personal history: Occupational or socio-economic history. Dietary history. Menstrual history in females. 1. GENERAL DATA  Getting to know the patient and taking his generals, no matter how much it seems like an administrative act, still has its considered place. It is a good opportunity to break the ice and start establishing optimal contact with the patient.  During this process, the doctor slowly gets to know the patient's personality, his professional, cultural and social profile, and these are data that can be used in the definition of some diseases. On the other hand, they are also necessary due to the correct identification of the patient, which often prevents possible, intentional or unintentional errors with serious consequences (substitution of the patient in relation to some procedures, in case of death, problems with financial and legal regulation, etc. ) which can also have legal consequences. • Gender indicates sex-linked diseases. • Age can exclude or confirm some diseases that refer to a certain period of life (childhood diseases, diseases of aging, etc.). • An accurate description of the profession and the workplace implies the possibility of occupational diseases, but it is also useful information about the psychophysical burden. • The place of birth and the place of residence can indicate a disease from the group of endemic diseases (goiter, nephropathy). 2. CHIEF COMPLAINTs Ask the patient regarding the main complaint for which he/she is seeking medical consultation. In this part of the history, only the symptoms and clinical signs for which the patient is seeking help are listed. Most of the patients have mainly one or two complaints which are recorded in chronological order easily (chest pain, breathlessness, headache etc. ). The question of duration of a complaint is difficult especially in old people and in uneducated people. Majority of patients do not remember the exact duration of complaints. In such a situation, approximate duration may be asked. 3. History of present illness • Ask the patient to tell the detailed story of his/her illness from the day it started till today, giving the details of treatment, if taken. Ideally, patient should not be interrupted while narrating the history. • During history, patient may tell the things or statements which are of no consequence; these should be ignored. • The patient here will be asked to tell what actually happens during these complaints or he/she should give full details of the symptoms. While listening to the history, a student/ physician can ask the patient to give more details about that specific symptom. • When a student/doctor has understood the story of illness, he should proceed with each main complaint turn by turn and examine it in details. The first step in history is to make sure that you and patient are talking about the same thing. • Sometimes, patient may use certain words which may have many meanings or may have different interpretation. In such a situation, one should clearly ask what does it mean actually. 3. History of present illness • Presentation of the history of the disease from the beginning of the basic complaint, the time of its appearance, the manner of occurrence, duration, localization, dynamics, spread, strength, conditions that provoke/potentiate or reduce it, accompanying complaints and the reaction to these phenomena. • All this is presented systematized in chronological order. Review of systems: • GENERAL SYMPTOMS: pain, body temperature, fever, sweating, weight loss – Skin: appearance of rashes and whatnot, change in color and whatnot, swelling, appearance of enlarged lymph nodes; – Head: headache; – Eyes: vision, inflammation, diplopia, photophobia; – Ears: hearing, pain, discharge from the canal, buzzing, dizziness; – Nose: change in the sense of smell, inflammation, secretion, bleeding, congestion; – Mouth and throat; dental condition, toothache, problems with chewing and swallowing, dry mouth, increased salivation, change in taste, change in tongue, scratching and pain in the mouth and throat, specific smell; – NECK: mobility, pain, pulsations, filled neck veins, enlargement in the front (thyroid), voice change, hoarseness, dysphonia, aphonia; Review of systems: RESPIRATORY SYSTEM: – slow, rapid or uneven breathing, difficulty breathing in inspiration, expiration or continuous, – chest pains and special attention to their connection with the act of breathing, change of position, – cough, occasional, in fits, continuous, occurrence and duration, dry or with sputum, description of sputum: copious or minimal, quality, color, smell, mucous, purulent, with admixtures of blood or bloody, – change in the chest, breasts (cheats). Review of systems: CARDIOVASCULAR SYSTEM : • Shortness of breath (dyspnea) graduated at rest and at different levels of effort, or in approaches, bruising. • Chest pain (atrial), location, involvement (pointing with finger or palm), type of pain (sharp, dull, burning, squeezing, tearing), intensity (mild, dull, moderate, severe), duration (short, long, intermittent ), irradiation (spread), causative-previous conditions related to its occurrence, accompanying symptoms (paleness, cold sweat, feeling of fear of imminent death, malaise, anxiety). • Palpitations-sensation of strong heartbeat, irregular work with skipping. • Syncope - short-term, usually reversible loss of consciousness. • Septic temperatures and prolonged fatigue. • Pain in the legs (shins), unilateral or bilateral during exertion or short walking - claudication intermitens. • Symmetrical bilateral, bright, cold, testy and plastic swellings (oedema) of the ankles, legs or abdomen. Review of systems: GASTROINTESTINAL SYSTEM: • appetite, nausea, special desire or aversion to a certain type of food, • vomiting and description of its characteristics, • nausea and heaviness in the stomach, mostly in the spoon: when in relation to the intake of food and type of food, • A feeling of sourness in the mouth with intense burning and pain behind the sternum, • Description of all the basic features of abdominal pain, abdominal colic, • Vomiting of blood (haemathemesis), • Blood in the stool (melena), rectalgia. • Stomach bloating, • Pain-all qualities (eg ulcer disease), • Ascites, • Jaundice, • Constipation (obstipatio) or Diarrhoea, description of contents. Review of systems: UROGENITAL SYSTEM : • Daily amount of urine (diuresis), • Daily frequency: polyuria, oliguria, anuria, dysuria, pollakisuria, nocturia, hematuria (microscopic and macroscopic), urinary retention or incontinence. • Description of color and possible smell of urine. • Pain: Lumbar dull pain (lumbargia); colic: renal, ureteral, ureteral, suprapubic complaints, perineal pain. • Urethral burning, change in the strength and amount of the stream (reduced), difficult start of the stream, pain during urination. • Ureteral secretion and description of qualities. • Specific swellings: on the face, especially around the eyes, around the malleolus or anasarca (description of all qualities of the swellings). • Undefined septic temperatures. Review of systems: • Menstruation: first menstruation (menarche), interval, rhythmicity or disturbance of rhythmicity, duration, quantity. Last menstrual period (date). Dysmenorrhea, metrorrhagia, irregular bleeding. Number of pregnancies, number of deliveries, number of abortions, premature births. Gynecological diseases, operations, fluor albus, etc. • Metabolism: Assessment of body weight, sudden increase or decrease in body weight, increased or decreased appetite, increased fluid intake needs. • Locomotor system: Pain, change in the range of joint movements (limited), localization, extent, duration, deformities. Atrophic changes of the articular and peri-articular apparatus. Weakened or minimal muscle function, muscle mass reduced to muscle atrophy due to their immobility. • Neuropsychiatric aspects (psychosomatics): state of basic mental functions, consciousness, communication, memory defects, paresthesias, dizziness, hypotensive and syncopal approaches, etc. History of prolonged or acute stress, nervous breakdown, emotional stability/instability, conflicts with the environment. 4. Past history of illness This part of the medical history include past illnesses and conditions: 1. Diseases experienced in early childhood (are heart murmurs, cyanotic (blue) episodes or defined heart defects registered 2. Suffered common childhood diseases, especially recurrent streptococcal infections, rheumatic fever, glomerulonephritis. 3. All past or present diseases (eg high blood pressure, diabetes, hyperlipidemia, etc.). 4. Previous illnesses, performed invasive and non-invasive procedures, surgical interventions and drug therapy. 5. Possibly present or past sexually transmitted diseases. Difficulties in sexual life: in the family and personally, and for the female sex everything related to the sexual cycle and reproduction (first menstruation and possibly the last), their regularity and possible abnormalities, pregnancies and deliveries, spontaneous or planned abortions, premenstrual difficulties, pre-climacteric and climacteric problems, post-climacteric condition. 5. Treatment (drug) history.  Regular use of medicines.  Identify the drug, the method of its use, the individual/daily dose and the duration of use, the reason for using it, which doctor recommended it or take it independently, the tolerability of the drug, side effects, etc.  Episodes of drug abuse-poisoning (accidental, suicidal)  Drug allergies/reactions  Regular vaccinations should also be recorded, by time and type. 6. Family history (Аnamnesis familiae) • Hereditary diseases in the family by blood line (hemophilia, some anemias, congenital and/or hereditary diseases, diabetes, hyper/dyslipidemia). • Then the possible cause of death of relatives from the first line of blood kinship is recorded. • The possible presence of diseases that have a family predisposition is noted, and these primarily refer to relatives from the first line of kinship (mother, father, brothers, sisters, grandmother, grandfather), namely: increased blood pressure, coronary artery disease, cerebrovascular stroke, allergies, ulcers, diabetes, malignant diseases, etc. • Also of interest are the so-called social infectious diseases such as: tuberculosis, hepatitis, HIV infection, etc. • • • • • 7. Personal history and lifestyle, Social hystory Habits about: smoking (length of time, amount, type), practice or not of regular physical activity, what and with what dynamics. Dietary habits (e.g. consumption of foods rich in animal products, salty foods, carbohydrates, dynamics and number of meals, method of preparation, etc.) and adherence to a diet. Alcohol consumption: regularity (everyday) and dynamics, amount and type of alcohol. Drug consumption (cocaine) and abuse of sedatives or other stimulants. Social conditions (social history). living conditions can have a significant place in the occurrence and development of some diseases. Therefore, some elements must be recorded, namely: a) living and working conditions: living conditions, humidity, heating, draft, ecologically unhealthy working environment; b) social-economic conditions: number of members in the family, number of family breadwinners, income, care for parents and other relatives, relations with the spouse and relatives, etc. c) profession: current and former, exposure to professional agents, financial situation) marital status, spouse, children, their health status Difficult situations 1. Patients with communication difficulties • If your patient does not speak your language, arrange to have an interpreter, remembering to address the patient and not the interpreter. • If your patient has hearing or speech difficulties such as dysphasia or dysarthria, consider the following: • Write things down for your patient if they can read. • Involve someone who is used to communicating with your patient. • Seek a sign language interpreter for a deaf patient skilled in sign language. Difficult situations 2. Patients with cognitive difficulties • Be alert for early signs of dementia. Inconsistent or hesitant responses from the patient should always prompt you to suspect and check for memory difficulties. If you do suspect this, assess the patient using a cognitive rating scale. You may have to rely on a history from relatives or carers. 3. Sensitive situations • Doctors sometimes need to ask personal or sensitive questions and examine intimate parts. If you are talking to a patient who may be suffering from sexual dysfunction, sexual abuse or sexually transmitted disease, broach the subject sensitively. Indicate that you are going to ask questions in this area and make sure the conversation is entirely private. • If you need to examine intimate areas, ask permission sensitively and always secure the help of a chaperone. This is always required for examination of the breasts, genitals or rectum, but may apply in some circumstances or cultures whenever you need to touch the patient. Difficult situations 4. Emotional or angry patients • Ill people feel vulnerable and may become angry and frustrated about how they feel or about their treatment. Staying calm and exploring the reasons for their emotion often defuses the situation. Although their behaviour may be challenging, never respond with anger or irritation and resist passing comment on a patient’s account of prior management. Recognise that your patient is upset, show empathy and understanding, and ask them to explain why: ‘You seem angry about something’ or ‘Is there something that is upsetting you?’ If, despite this, their anger escalates, set boundaries on the discussion, calmly withdraw, and seek the assistance and presence of another healthcare worker as a witness for your own protection. • Talkative patients or those who want to deal with many things at once may respond to ‘I only have a short time left with you, so what’s the most important thing we need to deal with now?’ If patients have a long list of symptoms, suggest ‘Of the six things you’ve raised today, I can only deal with two, so tell me which are the most important to you and we’ll deal with the rest later.’ looking (INSPECTION), feeling (PALPATION), tapping (PERCUSSION), and listening (AUSCULTATION) PHYSICAL EXAMINATION (Status praesens) COURSE OF THE DISEASE (DECURSUS MORBI) • In the history of the disease, this chapter records all the relevant data on the events that occur throughout the process of diagnosis and treatment. • All changes in complaints, physical findings, as well as all performed laboratory, paraclinical investigations and possibly new conditions are recorded exactly in time. • All consultations, therapeutic procedures and everything else related to the treatment are also recorded. • WRITTEN CONSENT of the patient (a document giving permission) for treatment measures, hospitalization, application of invasive and interventional procedures and other investigations, surgical interventions and application of some drugs, after their previous detailed explanation, are also included. (THERAPIA)  In this chapter of the history of the disease, it is recorded exactly when and what dynamics drugs were prescribed, their doses, the therapeutic effect and possibly manifested side effects, as well as the undertaken non-medicinal therapeutic procedures. - temperature list - FINAL DIAGNOSIS (DIAGNOSIS) • At the first contact, after taking the anamnesis, the physical examination and the basic paraclinical investigations are defined WORKING DIAGNOSIS, • The possibilities are also being considered DIFFERENTIAL DIAGNOSES, • Based on a system of confirmation and/or exclusion (diagnostic and therapeutic) it is arrived at DEFINITIVE (FINAL) DIAGNOSIS. FINAL DOCUMENT EPICRYSIS (medical report) OBLIGATION of the doctor and the institution where the patient was treated is to issue after the examination, treatment and follow-up WRITTEN REPORT (medical note), about everything done, the recommendations, advice and intentions given. One copy of the medical note remains in the institution's medical records.The document (LETTER OF DISCHARGE) with which the patient is discharged from a hospital institution should be particularly detailed and reliable, in addition to the possible judicial-medical and other legislative procedures. THANK YOU FOR YOUR ATTENTION - Homework -