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Approach to history taking in internal medicine posting

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Approach to history taking in internal medicine posting

  1. 1. Approach to History Taking in Internal Medicine Posting Purpose of history taking 1) Identify current problem and diagnosis 2) Exclude life threatening condition 3) Identify underlying medical problem 4) Progression of patient in ward 5) Response to treatment. 6) Any complication to the patient What do you need to cover in the history taking section 1) Identification data 2) Relevant Past Medical History 3) Chief Complaint 4) History of Presenting Illness 5) Review of the System 6) Past Medical and Surgical History 7) Drug History 8) Diet and allergic history 9) Family history 10) Social history 11) Summary of the history. Identification data. Identification data is very important as it will give you some clue of what the patient might have. It is because that some disease are more common in certain age group, sex, races and occupation. It also serve as a record which is important to see the progression of the patient and for the medico legal purpose (in case something happen to the patient, investigator would like to know whether the doctor seeing the patient within the expected time or not.) Basically, there are nine element to be covered in the identification data section. However, only 3+1 item is important when you presenting the case to the lecturers. The 3 items are a) Age
  2. 2. b) Sex c) Race d) Plus any of the other element that you think related to the patient including from the history. The other element that you must take but keep it to yourself and do not require you to present the info unless needed includes a) Occupation b) Address c) Date of admission d) Date of clerking (including time) e) Name of the patient f) Informant (only relevant in case where patient could not provide you the history for example in the case of pediatric, psychiatric patient, altered mental status with loss of ability to provide information. Examples 55 years old Malay gentleman Note: Male gender with age more than 45 years old is highly associated with risk of Acute Coronary Syndrome spectrum. 45 years old Chinese gentleman Notes: Chinese race is more prone to develop peptic ulcer disease, nasopharyngeal carcinoma. 36 years old Indian gentleman who works as long distance truck driver Notes: long distant vehicle driver is a high risk occupation that often associated with substance abuse or illegal sexual history. Relevant Past Medical History
  3. 3. Since you already have Past Medical History Section, therefore you only need to put only the most relevant problem which associated with current presentation. For example; Patient A presented with the complaint of sudden onset shortness of breath for three day duration. He is a chronic smoker, has history of admission to ward due to Ischemic heart disease last year, treated for dengue fever last 3 years and undergone appendix surgery when he was 12 years old. In this case, shortness of breath might alert the clinician of the possibility to have heart failure, acute exacerbation of COPD or Acute coronary syndrome. Therefore, the relevant past medical history that you need to put after the identification data are chronic smoker and history of admission due to ischemic heart disease. Meanwhile, history of dengue fever and appendix surgery is not important and only need to be covered in past medical history section. Chief Complaint This section might be a little bit tricky as patient might presented with a lot of complaint. Sometimes they may even complaint of more than 10 problems which might causing headache to the clinician. Furthermore, too many chief complaint may divert the clinician from the right path of making diagnosis. Remember that chief complaint is the MOST IMPORTANT REASON for the patient to come to the hospitals. It is what bringing them to you. Therefore, it is usually very severe or causing inconvenience to the patient. Limiting the chief complaint to not more than three symptoms may help you focus to the most important and worrisome problem. You should describe each symptom with its nature and duration. if there are more than one complaint, therefore mention the sequence in chronological order (which develop first) For example; In patient with known case of chronic heart failure, they may presented to you with acute on chronic heart failure or decompensated heart failure. Premorbidly, there are already having shortness of breath, but for the current presentation, it might have become worse and associated with other symptom like bilateral leg edema, chest pain (infection can worsen the heart failure). At the same time, patient might also having a collection of sign of upper respiratory tract infection (which also can trigger the decompensated heart failure but not really significant for the chief complaint). Therefore, you may construct the chief complaint as follow Pleuritic chest pain and worsening shortness of breath for 3/7 duration and bilateral leg edema for 1/7 duration
  4. 4. Putting the chief complaint in chronological order is also important as many disease share the same symptom but different condition. For example, bronchiectasis, pulmonary tuberculosis (PTB) and lung ca may presented with fever, haemoptysis and cough. However, the chronological order for each problem is different. Patient with bronchiectasis may have chronic cough, later develop hemoptysis and complaint of fever when they have superimposed bacterial infection. PTB patient may presented with fever first, followed by cough and hemoptysis. Meanwhile, lung ca patient may develop hemoptysis first and followed with fever and cough. History of Presenting Illness History of presenting illness is the elaboration of the chief complaint. It is served for 1) Making a provisional diagnosis 2) Exclude the differential diagnosis 3) Access the severity of the disease In history of presenting illness, you should make a list of differential diagnosis based on patient’s chief complaint to give you an idea of what question you should ask in order to obtain important information. There are two technique of taking the history which are open ended method and close ended method. Before I proceed, it is important for you to note that in taking the HOPI, you need to use the exact word from patient and not replacing it with medical jargon as you may mis interpret it. Open ended is by letting the patient to describe about his disease and if necessary, you interrupt a little to ensure that patient on the rail track and did not divert to other things. In other word, you guide the patient to tell their history for you to analyze the information. Meanwhile, close ended question is that you ask the question where patient only have yes or no option to answer the question. In taking history, open ended is the universal accepted method and should be practice. However, some time, you might need to use close method for example to confirm back what patient has tell you.
  5. 5. For example, in patient presented with shortness of breath, you can ask the open ended question like “can you explain more regarding the shortness of breath” Rather than straight away ask the patient “ Are you having shortness of breath when you do the exercise?” In obtaining the history of presenting illness, you may use this mnemonic to keep you in track and ensure that you collect enough information. However, for shortness of breath, a modification need to be done for the mnemonic which I will explain later. The mnemonic is as follow “LORD SANFARO” L- Location O- Onset R- Radiation (of the symptom to any part of body) D- Duration S- Severity A- Aggravating factor N- Nature F- Frequency A- Association factor R- Relieving factor O- Offset. For shortness of breath 1) You still follow the mnemonic except for the location and radiation plus some modification. 2) You need to access New York Heart Association grading of functional status (NYHA) in suspected heart problem. (Heart failure, Acute Coronary Syndrome, Heart abnormality) 3) Severity of dyspnoea and disability [Modified Medical Research Council (MMRC) dyspnoea scale] in case of COPD.
  6. 6. 4) Patient condition Premorbidly and during the problem, for example - Initially patient able to climb three flight of stairs but now having shortness of breath by only taking one flight of stairs. - Initially patient can perform the Solah normally but now need to pray while in sitting position. - Initially patient work but now need to quit his job because of shortness of breath. - Patient Premorbidly already need to depend on lifelong oxygen therapy. 5) Specific nature of the shortness of breath - On lying flat (orthopnea). You may ask patient how he sleep at night. How many pillow he use. For example, previously he manage to sleep with one pillow but now require more than one pillow and experience shortness of breath if reduce the number of pillow. In severe shortness of breath patient, they may need to sleep on sitting or tripod position. Worst is that, some of them even not able to sleep because of shortness of breath. - Paroxysmal nocturnal dyspnoe. Whereby patient suddenly wake up from sleep grasping for air. Some of them may describe that they are about to die and when wake up, they breath rapidly, need to take fresh air by opening the window and associated with sweating. Review of the System This section is to ensure that you not miss certain symptoms which are related or important to the current problem. Basically, you do not need to elicit all system but mainly system related to the current presentation. It should be brief (touch and go) and close ended method. For example, in patient with liver problem, you might want to know about central nervous symptom (hepatic encephalopathy), musculoskeletal system (flapping tremor, muscle weakness) and gastrointestinal system (Loss of appetite, loss of weight, change in bowel habit, abdominal tenderness). Here, I listed some of the check list for the review of the system. You may re- create the list by using a diagram method or check list box. General Weight loss Loss of appetite Specific diet Lethargy Fever Sleep disturbance Respiratory System
  7. 7. Shortness of breath Cough and running nose Hemoptysis Night sweat Cardiovascular system Typical angina pain Any other chest pain Shortness of breath Palpitation Giddiness Blurring of vision Syncope Gastrointestinal System Nausea Vomiting Abdominal pain Bowel habit Jaundice, pale stool, tea-colored urine, itchiness Difficulty in swallowing Genitourinary System Dysuria Urgency, hesitancy, frequency Hematuria Incontinence Endocrine System Sweating tremor Heat/cold intolerance Neck swelling Excessive drinking or eating Body weight changes Central Nervous System Headache Blurring of vision Numbness
  8. 8. Abnormal movement and convulsion Loss of consciousness Musculoskeletal System Joint pain or stiffness Muscle pain and muscle weakness Bone pain Past Medical and Surgical History In this section, you list all the past medical history that the patient have, excluding the problem that you have already covered in Relevant Past Medical History. You need to exclude the chronic disease like hypertension, diabetes mellitus, tuberculosis, asthma. When you are describing this section, please note on the item. Every disease need to have the following item. 1) When it is diagnosed 2) How it is diagnosed 3) Who diagnosed it 4) Currently on follow up at which care setting 5) What treatment that the patient undergone (pharmacology just outline briefly as it will be covered in drug history, non pharmacological) and whether compliant to the medication or not. 6) Is the problem resolve or did patient develop complication. And plus (after you finish describing all medical problem. 7) When it is the last time patient admitted to the hospital and due to what? 8) Any known syndrome? For example, in patient with diabetes mellitus “Patient was diagnosed with Diabetes Mellitus 10 years ago by the doctor in HUSM after he develop polydipsia, polyuria, polyphagia and lethargy. Currently he is under HRPZ II follow up and on two type of oral hypoglycemic agent. He is also on diabetic diet. Patient has history of admission due to the complication of DM which includes diabetic foot last year and
  9. 9. hypoglycemia early this month. Currently he is also develop diabetic retinopathy and diabetic dermatopathy. Currently he do not have diabetic nephropathy yet.” Drug history The best is for you to ask the patient to show their medication box. Some patient may also have a medication card which list the type of medication that he currently take. If patient could not tell you the specific type of drug, then you can just mention it generally like on two type of oral hypoglycemic agent or describe the appearance of the drug like, small orange round tablet for hypertension. It is also important to elicit the use of traditional medication especially herbs. Any allergic to drug also need to be elicited. For example, allergic to penincillin based antibiotic, diclofenac sodium or even paracetamol. If patient using the inhaler, you can mention on what type of inhaler (metered dose inhaler, handihaler, turbohaler) and medication (reliever vs controller). Diet and Allergic History This is so important! Most of the stable patient may consume normal adult diet. But in patient with specific illness, you need to pay attention on this problem. For example You need to elicit salt intake in hypertensive and heart failure patient. Basically their salt requirement is one and half tea spoon per day without any additional source of salt (salty fish, anchovy sauce). Next is regarding fluid restriction in chronic renal failure and congestive cardiac failure (basically 500 ml to 1L per day) or diabetic diet in diabetic patient. Patient on hemodyliasis may require high protein diet in contrary to patient with nephrotic syndrome who require low protein diet. You also need to access nutritional status in patient who is cachexic, anemic patient or patient with thyroid problem. Allergic to food is SO important. Most of the patient allergic to peanut or sea food. However, remember that different patient may have different allergic history to different type of food. Some patient may also have taboo on certain food. Plus, some food may also give adverse reaction with the drug that patient currently take for example grapefruit juice and calcium channel blocker.
  10. 10. Family history Family history play a big role as most disease has genetic element than can be passing down from generation to generation. This also explain why some patient are prone to certain type of disease while the others are not. The family history is taking in the manner of first degree relative. For example, patient and his father are first degree relative, patient and his sibling are his first degree relative. And patient and his offspring is also a first degree relative. In taking the family history, you should take the three generation family history. For example, if patient is married, then take history from his parent and also his offspring. If he did not have offspring yet, then you may take history up to his grandparent. However, it is not necessary to take full three generation history of other than first degree relative except when you are dealing with genetic or Syndromic patient. Spouse medical illness like asthma, cardiac disease are not important for patient because they are not genetically connected (except in consanguineous marriage). However, if patient having a transmissible diseases like tuberculosis, sexual transmitted disease, therefore it is significant. The same thing apply between the relationship among the step brother or sister. However, for the relationship between patient and their half siblings, it is indeed important as they still carry the same genetic from either paternal or maternal site. When the relative is already die, you need to elicit at what age did the elative die. If patient said that relative is died due to old age, you need to verify back the age. Some may consider age 60 is already an old age even though the definition of elderly is more than 65 years old. It is important as well to identify any relative died of sudden death before the age of 45 as it may signify heart related problem. Social history Under the social history, you can elaborate it under few category 1) Smoking For smoking history, you need to calculate the pack smoke per year which can be calculated using the formula No of cigarette stick X year of smoking 20 stick
  11. 11. You may also just mention how many stick did the patient smoke per day without expressing it in pack smoke per year. It is particularly very important for you to identify the type of smoking. For example, branded cigar, self made cigarette, branded cigarette, chewing the tobacco. Please noted that shisha is not considered as smoking. 2) Alcohol intake + sexual history I need to remind you that an alcohol history is very sensitive, base on my limited experience, a patient might appear pious but during his young time, he might have history of drinking alcohol. Therefore, it is best to reserve the sensitive question at the end of your interview. This is also imply to the sexual history. Please note that before you ask the sensitive history, you need to remind the patient first that you are about to ask regarding a very personal and confidential history. Re assure the patient that it is your duty to ask the question and their honesty is very important in answering the question. Trust me, it is most appropriate to ask this two history when the relative is not present near the patient. 3) Financial history Ask for patient occupation and salary. If patient is sick and could not work, ask regarding the source of income. Where did it come? Who’s paying the medical fee? Is patient having medical insurance? 4) Social support Ask who is taking care of the patient while he was admitted. How about patient’s children at home. Who is taking care of them while he is sick. Access whether the social support is adequate or not and whether this is a case of ‘neglected’ by the family member. 5) House condition Ask patient stay with whom? Is the house belongs to the patient or rented. How many storey is the house? Let say patient have heart failure or COPD and stay at second floor of his house, then you might need to consider that patient have to change his bedroom to the ground floor.
  12. 12. Is there any pet and carpet in his house. How’s the oxygenation of the house. This all will affect the patient with asthma or COPD. Is the house well supplied with electricity and water supply. Is the patient using coal as a burning material at home as it will also affects the COPD patient. Summary of the history. Writing a summary of the history is challenging and it require a lot of practice before being able to produce a very good summary. A good summary should be brief, concise, clear and require your interpretation of the patient’s symptoms. The idea is like presenting it tho the person who did not listen to your full history and yet they can grab the full picture of what happen to the patient. The purpose of the summary is to sell your provisional diagnosis. In the summary of the history, the item should be listed 1) The 3+1 identification data 2) Relevent past medical history 3) Your interpretation of patient symptoms into medical words 4) Your assessment and provisional diagnosis. For example 65 years old Malay Gentleman who is a chronic smoker with past medical history of hypertension for 20 years and chronic heart failure since last year currently present with decompensated congestive cardiac failure by evidence of severe shortness of breath, orthopnea, paroxysmal nocturnal dyspnoea and bilateral leg and scrotal edema.

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