Physical Diagnosis Mod 3 Fundamentals of History Taking PDF

PHYSICAL DIAGNOSIS 08/24/2024. MOD 3: FUNDAMENTALS OF HISTORY TAKING...

PHYSICAL DIAGNOSIS 08/24/2024. MOD 3: FUNDAMENTALS OF HISTORY TAKING Dr. Coleen Gulay, MD, FPCP, FPCCP Trans Group/s: 1B I. HISTORY TAKING A good medical history which contains significant and The first step in physical diagnosis relevant information regarding the patient’s disease ○ Obtaining an accurate history is the first critical progression contributes to better diagnostic and step in determining the etiology of a patient’s illness therapeutic decisions that leads to patient satisfaction. A process by which information is gained by the ○ Good medical history → accurate diagnosis → physician by asking specific questions to the patient appropriate management → patient’s satisfaction with the aim of gathering information that will be useful in forming a diagnosis to be able to provide II. MEDICAL HISTORY appropriate medical care. Medical history is a compilation of a series of events An integral part of clinical practice, enabling in the patient’s life that have relevance to his or her physicians to make accurate diagnoses. mental and physical health. As a student, it is important to learn this skill and be able It is written by a health provider, trainee, or student to apply it to your future patients. based on facts provided by the patient or key informants which is usually offered spontaneously or by skillful probing. Table 1. Privileges and Responsibilities of the Physician A. OBJECTIVES OF HISTORY TAKING PRIVILEGES RESPONSIBILITIES 1. BUILD THE RELATIONSHIP Ask personal questions Be sensitive and In history taking, the physician builds a rapport with and physically examine considerate of your the patient and gains his confidence by the patient patient’s feelings, both communicating a sense of personal caring — emotional and physical. establishing eye contact, speaking in a calm and relaxed voice, and listening intently to the patient are all Allowed and expected to To inform them diligently essential during the course of the medical interview. ask even the most and clearly the reasons for intimate questions we such inquiries. 2. ASSESS AND UNDERSTAND THE PATIENT’S think would matter in PROBLEM forming accurate diagnosis. In assessing and understanding the patient’s problems, obtain all relevant information for you to be able to The combination of privilege and responsibility demands come up with an initial diagnosis. not only that you develop skill in examining a patient but Elicit manifestations of the disease as perceived by also you develop stability and insight that you aim the patient. clearly for the benefit of the patient. ○ Overtime, one will be able to discern the facts from those that arise from the patient’s own perceptions A. IMPORTANCE OF A GOOD MEDICAL HISTORY or reactions to the disease. Medical history is a very important element in making an accurate diagnosis. 3. COLLABORATE FOR MANAGEMENT ○ It is an important source of information to diagnose a disease. Lastly, it can help us educate our patients for shared Aside from clinical history, physical examinations decision making in the management of his or her and laboratory tests are the basis of diagnosing a illness which can also motivate them for adaptive health disease. behaviors. However, studies have shown that almost 76% of the For example: history of cigarette smoking can trigger time you will be able to make a diagnosis based on physicians to advise smoking cessation. history alone. B. GENERAL APPROACH IN HISTORY TAKING GENERAL APPROACH IN HISTORY TAKING Ideally, conduct medical interviews in private if Conduct possible. 1 medical interviews in Otherwise, patients may be private unable to describe their Basis of Diagnosing a Disease illnesses clearly and may omit Physical Diagnosis - Mod 3 Fundamentals of History Taking 1 of 6 The use of trans, practice questions, and evals ratio must be used discreetly and social media/public exposure of the aforementioned shall be strictly prohibited.  1. DEFINITION OF TERMS or hide important information. The very first step in starting DEFINITION OF TERMS their interview is to introduce Introduce oneself and read the Refers to the source/s of the history 2 whether from the patient or others (i.e. yourself patient’s data making sure that you have his or her name relatives, by-standers). Informant right. Among neurologic and pediatric patients, the informant is usually a State the Inform the patient the reason relative. 3 purpose of the for interviewing him/her. interview Abnormal sensation perceived by the patient/s — a manifestation of a Greet your Talk to patients in a disease by the patient patient in a courteous, relaxed manner. Symptom Subjective 4 Medical history: represent the courteous but relaxed manner complaints of the patient Example: difficulty breathing, cough A relaxed conversation style Put the patient promotes a more comfortable Noted by examiner —a manifestation 5 of a disease based on the examination at ease feeling on the part of the person involved. of a physician Objective Sign Establish eye Physical exam: examiner’s physical 6 contact during findings the interview Example: tachypnea, respiratory rate, crackles, wheezes, stridor Ask the 7 necessary data C. COMPONENTS OF MEDICAL HISTORY Begin with the general and COMPONENTS OF MEDICAL HISTORY 8 follow with the specific as the 1 General Data story unfolds 2 Chief Complaint Avoid closing the conversation with questions to which the 3 History of Present Illness Use open-ended only answer is a yes or no. 9 questions Leading questions should 4 Past Medical History be avoided but can be used when the situation calls for it. 5 Family History Give your Give the patient time to 6 Personal and Social History 10 patient time to respond to his or her own. respond 7 Review of Systems Listen attentively and sympathetically to your 1. GENERAL DATA Show interest patient’s making a few and concern for 11 interruptions. Follow the Includes general information and demographics of the feelings of patient’s lead when the the patient that can immediately narrow down the list of the patient patient describes how he feels diseases that we would consider. and relates his problem. GENERAL DATA Pay attention and explore 12 Catch cues further to non-verbal cues. Patient’s 1 name Complete name/initials At times it may be necessary Demonstrate Certain diseases are more for you to help your patients 13 control of the common either in the very minimize irrelevant interview 2 Age young or in the very old discussion. Some diseases equally affect all age groups Clarify lay terms such as “not With gender, we would probably feeling well”, not immediately consider breast 14 “stomach 3 Gender cancer in men and never discomfort”, consider scrotal carcinoma in “dizziness” females Physical Diagnosis - Mod 3 🏠 Fundamentals of History Taking 2 of 6 The use of trans, practice questions, and evals ratio must be used discreetly and social media/public exposure of the aforementioned shall be strictly prohibited.  Single ○ The history of the present illness begins with chief 4 Civil Status Married complaints or also known as the Index Symptom. Widower NOT a sentence. Brief statement/symptom why he sought medical There are certain diseases that attention are common among certain ○ It is the patient’s own words of what is the Nationality/ perceived problem or symptom as to why he 5 Race races Example: sickle cell anemia sought medical attention among afro-americans If verbatim (e.g., descriptive, unusual, or unique), place in quotation marks. Important because it can be a Regardless of what disease the patient is suffering factor in management from, the best way to elicit the chief complaint is to ask 6 Religion Example: in some religion, they directly: are not amenable for blood ○ “What symptom/sign brought you here?” transfusion ○ Why were you brought to the hospital?” A chief complaint is only a single symptom. However, May also be a risk factor for patients may volunteer more than 1 complaint during some illnesses history taking. 7 Occupation Example: coal miners have high ○ For patients with multiple complaints, one of risk for certain occupational them will predominate. diseases ○ Choose a symptom that led the patient to seek medical attention then include other symptoms May be important in some either in the history of present illness (HPI) or diseases which are locally review of systems, paying attention to how these predominant in some areas symptoms are related and associated to one Place of Birth Example: a patient coming from another 8 & Residence Palawan complaining of fever ○ Example: A patient complaining of fever and also would probably include malaria having headache during the fever, fever can be as a consideration because of its documented as a chief complaint, and will be high prevalence in the area elaborated fully in the history of present illness Specially for similar complaints (HPI). The headache is included in the HPI as an in the same hospital, may associated symptom. reflect the severity of disease If the patient is unconscious or incoherent, ask the or current nature of the illness closest person what happened and why he was brought 9 Number of One limitation is that this only to the hospital Admission DO NOT accept a diagnosis from a patient as a chief induces admission in the same hospital. This limitation may be complaint offset by a more detailed past Try to clarify what the patient is trying to tell. medical history ○ In some cases, the use of quotation marks means what the patient said from his/her perspective, but A person being admitted in the this may NOT actually reflect what really is wee hours in the morning or happening. late evening is more likely ○ Example: “Sumuka ng dugo” – coughing out of Time & Date perceived by the patient or family blood (hemoptysis) or vomiting of blood 10 of Admission (hematemesis) to be more serious than someone who waits until This needs clarification on whether the patient morning, although there are a lot was coughing out blood or vomiting out blood of exceptions to this ○ Example: Anemic vs Low Blood Patients may consult “low blood” which for Handedness Asking the patient if he is right or them may mean anemia. 11 (for neurological left handed is important cases) especially for neurological cases 3. HISTORY OF PRESENT ILLNESS (HPI) A concise, clear, and chronological description of the 1.1 Example problems, prompting the patient’s consult A thorough elaboration of the chief complaint and A.A., 55 years old, male, married, Filipino, Roman other current symptoms Catholic, businessman, born and presently residing in Contains the most important data concerning a Dasmarinas, Cavite was admitted to DLSUMC for the patient’s disease/illness first time on August 29, 2024 at 9:00 AM. Should be presented in a chronological and This example contains the general data needed such as sequential manner the patient’s name, age, gender, civil status, ○ Starts from the time the patient last felt “well” nationality/race, religion, occupation, place of birth, until the time of consultation residence, number of admission, and time and date of Onset of chief complaint ≠ the onset of present illness admission. ○ Example: Patient sought consultation due to fever. For privacy and confidentiality, the patient’s initials are However, on further questioning, you discovered used, rather than their full name during reporting or that the patient was apparently well until he/she endorsement. had a cough 5 days ago. Thus, while the chief complaint is fever (the reason for seeking 2. CHIEF COMPLAINT consultation), your HPI will start from the characterization of cough 5 days prior to Primary problem or condition prompting visit consultation. Physical Diagnosis - Mod 3 🏠 Fundamentals of History Taking 3 of 6 The use of trans, practice questions, and evals ratio must be used discreetly and social media/public exposure of the aforementioned shall be strictly prohibited.  ○ That’s why it is advisable to ask probing questions such as: Expected findings if a possible cause “When did you start feeling something wrong for a patient’s problem were true → with yourself?” WEAKEN the diagnosis by their “When did your illness start?” absence Aside from the onset of symptoms, one should be able to elicit the details of the present problem Clarify the possible causes of the patient’s condition Make sure to ask about the other attributes of every as well as eliminate other less likely possibilities. symptom the patient experiences. HPI is a process of probing with questions similar to ○ Onset testing a hypothesis. ○ Precipitating Factors ○ With each question, the list of probable diagnosis ○ Course of Progression of Symptoms or hypothesis is torn down until a few likely choices ○ Quality are left from a formerly longer list of diagnostic ○ Location/Radiation possibilities. ○ Relieving Factors ○ Setting Associated Symptoms 3.2 History of Patient’s Illness Do’s & Don’ts ○ Timing DO NOT use numbers in starting a sentence but rather Example: Symptom — pain spell out the number you want to specify ○ 4 months prior to admission → Four months prior to “OPQRST” admission DO NOT use dates. It is better to just estimate the Onset When did you first notice the pain? period prior to consult (out-patient) or admission What were you doing when the (admitted) pain started? ○ On August 29, 2021, patient developed cough → Patient was apparently well until five days prior to consult Precipitating Does anything make it worse? Is it Refrain from mentioning the name of the physician worsened by effort? the patient consulted. ○ Instead, the name of the physician can be changed Palliating Does anything make it better? Is it to anonymous terms such as “private physician” or relieved by stress? “family physician.” ○ E.g. Progression of Did the symptoms worsen from The patient sought consult with Dr. Juan dela symptoms before? Cruz. The patient sought consult with a private Quality Can you describe the pain for me? physician. Was it sharp, dull, or aching? In stating medications, always practice to place the generic names of the medicines taken by the patient, Region/Radiation Where did the paint start? Does it followed by the brand name if specified. spread anywhere else? ○ Avoid using brand names solely. ○ E.g. Severity On a scale of 1-10, with 10 being The patient was self-medicated with the worst possible pain, how would Augmentin 625 mg tablet 3x a day for 7 days. you rate your pain? The patient was self-medicated with Co-Amoxiclav (Augmentin) 625 mg tablet 3x Associated Is it associated with coughing or a day for 7 days. Symptoms other symptoms? 4. PAST MEDICAL HISTORY Timing or How frequent does it occur? How Temporal long does the headache last? Contains information about the patient’s medical characteristics (duration) Does it happen during problems or surgical procedures that occurred before nighttime or daytime? the onset of present illness. Should be presented in an outline form by using bullets for short sentences. 3.1 History of Patient’s Illness Past medical history consists of the following: Include PRESENCE or ABSENCE of additional ○ Adult illnesses symptoms Medical: include current medications (dose, ○ Other relevant information that may help generate route, and frequency of use), if any a list of possible causes or differential Surgical: previous hospitalizations or surgeries diagnosis to explain the patient’s problem or E.g. condition ○ April 2019 — Admitted for dengue, Ospital ng Maynila Presence of symptoms related to the ○ July 2021 — Operated on for chief complaint appendectomy, Jose Reyes Medical Pertinent Expected findings if a possible cause Center positives for a patient’s problem were true → Psychiatric SUPPORTS your “DIAGNOSIS” by ○ Childhood illnesses their presence ○ Injuries / accidents / trauma ○ Allergies ○ Immunization Pertinent Symptoms that are NOT present negatives Physical Diagnosis - Mod 3 🏠 Fundamentals of History Taking 4 of 6 The use of trans, practice questions, and evals ratio must be used discreetly and social media/public exposure of the aforementioned shall be strictly prohibited.  PAST MEDICAL HISTORY 7 Lifestyle Lifestyle habits that promote health or create risk 1 Patient’s comorbidities Type of habitat and water supply 2 Current medications 7. REVIEW OF SYSTEMS 3 Previous hospitalizations It is a rundown of the other symptoms the patient may 4 Surgeries be experiencing. It is a checklist arranged according to organ 5 Injuries / Accidents / Trauma systems. This is a way to uncover any overlooked problems, 6 Allergies demonstrating the physician’s responsibility for the patient’s total well-being. 7 Immunization Record all pertinent symptoms. ○ Symptoms already mentioned in the HPI do NOT to be included in the review of systems. 5. FAMILY HISTORY Presence or absence of illness/es among the SYMPTOMS BASED ON ORGAN SYSTEMS patient’s immediate relatives. ○ This is important in familial diseases. 1 General (constitutional symptoms): weight loss, ○ Example: Diabetes, Asthma, Cancer, Heart fever, weakness, etc. Disease, and Hypertension. 2 Integument (skin, hair, nails) Presence of similar illnesses in the household should also be asked especially when considering 3 Hematopoietic environmental or contagious illnesses (e.g., TB, COVID). 4 Head Example of Family History: ○ Asthma, mother and sister 5 Eyes ○ Breast cancer, maternal aunt ○ Diabetes, paternal grandfather 6 Ears ○ No family history of hypertension 7 Upper respiratory tract (nose, nasopharynx, and It is important to specify the relationship of the family paranasal sinuses) member with the illness to give a clearer picture of the patient’s family history. 8 Mouth 6. PERSONAL AND SOCIAL HISTORY 9 Breasts Can show risk factors of the patient for lifestyle 10 Respiratory tract diseases. Vices such as smoking, alcohol drinking, and illicit 11 Cardiovascular system drug use are included. 12 Gastrointestinal PERSONAL & SOCIAL HISTORY 13 Urinary tract 1 Diet 14 Genitals / sexual 15 Menses / obstetrical 2 Alcohol Important to break down the kinds of alcohol intake and the 16 Musculoskeletal average intake in a day or week. 17 Nervous system 3 Smoking Defined in pack years to 18 Endocrine system History understand duration and 19 Emotional / behavior dosage of smoking. ○ Pack years = (# of Cigarettes per day / 20) x # III. GENERAL APPROACH IN HISTORY TAKING of years of smoking Summarize intermittently to reinforce data gathered ○ Number of cigarettes per ○ DO NOT forget to give a closing statement. pack is 20. ○ Allow the patient to conform or disagree with the Ask about the intake of data gathered. cigarettes daily. Always thank the patient for their cooperation. Physician-patient relationship is built on trust, hence 4 Illicit Drug Intake at the end of the medical interview, maintain confidentiality on the data gathered. 5 Educational Can also be elicited (optional) Attainment CHARACTERISTICS OF A GOOD HISTORY 6 Employment Patient’s occupation 1 Concise Physical Diagnosis - Mod 3 🏠 Fundamentals of History Taking 5 of 6 The use of trans, practice questions, and evals ratio must be used discreetly and social media/public exposure of the aforementioned shall be strictly prohibited.  2 Complete 3 Third-person perspective 4 Do not leave large gaps between timelines. 5 Give a good trend as to the progression or worsening of symptoms. 6 Give details as to the dimensions of magnitude, duration, intensity, location, quality, aggravating, or alleviating factors in associated symptoms. “Patient care begins with caring for the patient.” – FW Peabody Patients are individuals with problems, not cases of disease. Treat them with compassion and care, a dose of humanity will go a long way. Physical Diagnosis - Mod 3 🏠 Fundamentals of History Taking 6 of 6 The use of trans, practice questions, and evals ratio must be used discreetly and social media/public exposure of the aforementioned shall be strictly prohibited.