130925P - REVIEW: MAJOR SECTIONS OF A MEDICAL HISTORY

Paper written by Professor Omar Hasan Kasule Sr. MB ChB (MUK), MPH (Harvard), drPH (Harvard)

THREE PHASES OF THE MEDICAL INTERVIEW:

·         Opening

·         Exploring and focusing

·         Closing (p. 11 Clark and Kumar)

MAJOR SECTIONS OF A GENERAL MEDICAL HISTORY1: Demographic/basic info about the patient

·         Preferred name and title, 

·         Age,

·         Gender,

·         Ethnicity,

·         Residence/address

·         Occupation

·         Marital status

·         General condition: appearance and behavior.

MAJOR SECTIONS OF A GENERAL MEDICAL HISTORY 2: presenting complaint and related factors

·         History of the presenting illness/complaints or Description of the presenting problem: Account of the presenting illness covers recent changes in health status, associated triggering factors, and all changes that have occurred from the start until presentation to the physician.

·         Risk factors for illness:

·         Background history: 

·         Systems review: History taking is completed by a thorough review of the organ systems. The patient is asked specific questions about symptoms in each system that may have relevance to the presenting complaint.

MAJOR SECTIONS OF A GENERAL MEDICAL HISTORY 2: Past Medical History

·         Past medical history covers health status and disease experiences as back as can be remembered. It includes medical, surgical, and psychiatric conditions.

·         Both severe illnesses requiring hospitalization and less severe ones treated symptomatically or not treated at all need to be recorded if they have relevance to the presenting illness.

·         The interviewer must have an extensive knowledge of disease epidemiology and disease pathophysiology to know what relevant questions to ask.

MAJOR SECTIONS OF A GENERAL MEDICAL HISTORY 3: Family, social history, and occupational history

• Family history elicits information about diseases in immediate family members because the presenting illness may have a familial hereditary basis or an environmental basis in the domicile of the patient.

·         Social history: Social history elicits information about social factors that are relevant to disease such as marital status, education, lifestyle (eg alcohol, drugs, smoking), and beliefs.

·         Occupational and environmental exposures should be documented for a long time before the presenting illness because for chronic diseases the causative agent may act years before the presenting illness.

HISTORY OF THE PRESENTING ILLNESS/COMPLAINTS OR DESCRIPTION OF THE PRESENTING PROBLEM

·         What: problem brought you to the hospital? What does it feel like?, what brings it on?, what else?

·         Where: show me where it is

·         When: when did it start?, when does it occur? How often? How long for?

·         How: how bad is it? How is it increased? How is it decreased?

·         Why: why do you think caused it?

·         Who: who is affected by it (Lloyd and Bor p.30)

RISK FACTORS FOR ILLNESS:

·         Based on symptoms and general medical knowledge,

·         Must include common risk factors like smoking, food, foreign travel,

·         Previous surgical and medical treatment, injuries.

SYSTEMS REVIEW 1: CARDIOVASCULAR

·         cough/sputum

·         shortness of breath

·         wheeze

·         chest pain

·         palpitations

·         ankle swelling

SYSTEMS REVIEW 2: GASTRO INTESTINAL.

·         Appetite

·         Weight change

·         Difficulty swallowing

·         Heartburn

·         Nausea/vomiting

·         Abdominal pain

·         Abdominal swelling

·         Bowel: frequency/consistency/rectal bleeding

SYSTEMS REVIEW 3: UROGENITAL.

·         Dysuria

·         Frequency,

·         Nocturia,

·         Hematuria,

·         Testicular pain/swelling,

·         Problem urinating,

·         Menstrual details,

·         Obstetric history,

·         Contraception)

·          

SYSTEMS REVIEW 4:  NERVOUS.

·         Headaches,

·         Faints,

·         Fits,

·         Consciousness,

·         Numbness/tingling,

·         Eye sight,

·         Hearing,

·         Speech,

·         Mood,

·         Memory,

·         Concentration,

·         Weakness/wasting limbs 2.

SYSTEMS REVIEW 5: ENDOCRINE

·         Polydipsia

·         Polyuria,

·         Hot/cold intolerance,

·         Hair change

PAST MEDICAL HISTORY

·         Previous general health

·         Previous illnesses,

·         Admission to hospitals,

·         Operations,

·         Accidents and injuries,

·         Pregnancies),

FAMILY HISTORY

·         Genetics,

·         Impact of illness on family,

SOCIAL HISTORY

·         Family structure

·         Lifestyle

·         Occupation

·         Smoking

·         Drinking

·         Drug use

·         Sources of stress