This medical history document provides information on a 56-year-old male patient who was admitted to the hospital for inability to move his lower extremities. It details his present illness beginning with low back pain after lifting a heavy object that progressed to weakness, numbness, and paralysis in his lower legs and inability to urinate. It also includes his past medical history of benign prostatic hypertrophy, current medications, allergies, and review of systems. The document comprehensively outlines the patient's chief complaint and history of present illness to inform his diagnosis and treatment.

1. The truth in medicine
History
PE
Studies

2. Definition
 An account of the events in the patient’s life that have
relevance to his or her mental and physical health

3. Objectives
 Discovering symptoms
 Obtaining accurate quantitative descriptions
 Securing a precise chronology of events
 Determining how the illness has changed the
patient’s life

4. Establishing an
Effective Patient-
Clinician Relationship

5. Purposes of medical interview
 Collect information about patients and illnesses
 Establish a therapeutic contract
 Understand patient’s environments
 Establish list of problems that should be solved
 Develop problem-solving plans that encompass
> diagnostic studies
> therapy
> education of patient and his family

6. Proper collection of information
 Precision and specificity
 Quantitative evaluation
 Completeness

7. Requirements for good rapport
 Communication skills
> most important factor
> avoid frank discussion
> patient’s concern:
- severity of their symptoms
- possibility of recovery or death
- effect of illness on personal activities
- embarrassment of having to disrobe for PE
> sensitivity

8. Requirements for good rapport
 Trust and confidence
> Trust in professional skills
> Personal trust
> Patient’s expectations:
- cause of symptoms located and corrected
- some reassurance
- feeling of well-being after treatment
> deal expectations realistically

9. Requirements for good rapport
 Independence: If the clinician
> is completely authoritarian
> exercises some authority
> moderates the use of authority
> encourages the patient to collaborate actively
 Therapeutic contract
> patient expects accurate diagnosis and
appropriate treatment
> clinician expects patient to provide accurate
information and follow treatment regimen

10. Interview Strategies

11. Interview components
 Opening: intro, social talk, open-ended question
 Middle: open-ended to specific questions
 Closing: prelude to PE
 End of visit: after PE, answers patient’s question,
what he thinks is wrong, outlines diagnostic and
treatment plan: diagnostic tests, meds, follow-up
interview

12. Types of interview
 Direct-question interview
 Open-ended interview: requirements
> setting that encourages spontaneous behavior
> freedom to speak
> awareness of verbal and non-verbal communication
> little direction to the interview, progression

13. Types of interview
 Specific questions: guidelines
> general to specific
> less personal to more personal
> worded, not answerable by yes or no
> worded, interviewer’s bias not injected
> speaking patient’s language

14. Interview
Responses

15. Responses
 Facilitation (nod)
 Repetition (return)
 Silence
 Confrontation (crying, angry or anxious, contrast
between verbal and non-verbal messages,
inconsistencies)
 Support and reassurance: patient expresses strong
feeling, crying or releasing fear or anger

16. Responses
 Summation: purposes
> demonstrates interviewer’s interest in history
> lets patient know exactly how well the interviewer
has understood his account
> allows classification of patient’s history
> refocuses some particular aspect of the history

17. Case Analysis
The 27 year-old wife of a surgical resident and
mother of one child says that, after the first 6 months of
marriage, she had never attained a sexual climax during
intercourse with her husband. During her pregnancy, her
husband showed no interest in her but a male friend did;
she had a sexual orgasm with him. Her husband was more
interested in her after pregnancy. As far as she is
concerned, sexual relations between them and now are
acts without feeling. She concludes by saying, “He
demands to have sex with me. Sometimes I refuse, but
other times I let him and then can’t wait until it is over. I put
on an act so that he thinks I am enjoying it, but I don’t
enjoy it. If you ask him, he would probably say that I have
an orgasm every time.”

18. Case Analysis – Possible responses
Summation Response Explanation
“You say that he doesn’t know whether
or not you have an orgasm.”
Clarifies the history
“You say that he demands to have sex
and you can’t wait until it is over.”
Questions the patient’s account
“You say that you put on an act and
you don’t let him know how you really
feel.”
Focuses attention on another aspect
of the history
“Your husband apparently has a strong
sexual attraction for you. You get no
enjoyment from sexual relations, but
you act as if you do.”
Summarizes and refocuses the
husband’s behavior in a more
favorable light, which may be useful
when counseling the couple later. Bias
has been inserted for purpose.

19. The Complete
Medical History

20. Sequence
 Identification and vital statistics
 Informant, relation to patient
 Chief complaint
 History of present illness
 Medications and allergies

21. Sequence
 Past history
- General health
- Infectious diseases
- Operations and injuries
- Previous hospitalizations
- Review of systems; pertinent positive & negative
> Integument
> Lymph nodes
> Bone, joints and muscles
> Hematopoetic system

22. Sequence
> Endocrine system
> Allergic and immunologic history
> HEENMT
> Neck
> Breast
> Respiratory system
> CV system
> GI system
> GUT system
> Nervous system
> Psychiatric history
 Social history
 Family history

23. HPI
 Procedure
 Searching for diagnostic clues
 Attributes of pain: PQRST
 Nature of the symptoms: clarification & quantification
 Chronology
 Current activity

24. Sample
Five to six years ago, Mrs. Jones noted the onset of
weakness in right arm and hand. This, in retrospect, is
more incoordination than weakness. She could not use
right arm and hand as well as left, e.g. coffee cups. She
had mild numbness in right arm also. She saw several
MDs and had spine x-rays, EEG, etc., but no diagnosis
was made. Since then she has had very little problems
with arm. She has continued to have these problems but
does not believe they are more frequent or more severe.
She was told 8-9 years ago that she had high blood
pressure. She was given meds which she took for only a
short while. Six years ago she saw another MD, who said
she had hypertension but denies paroxysms of weakness
suggestive of adrenal disease or episodes of headache,

25. Sample
flushing or tachycardia.
For past several months she has noted feeling of
faintness and blurred vision on 3-4 occasions lasting
several to 30 minutes. These have occurred while walking
and do not seem to be positional in nature. She sits for a
while, and it passes. They are not associated with tinnitus,
vertigo, nausea, sweating, hunger or palpitations. She has
no syncope.
For the last 8 or 9 months she has noted occasional
inability to say what she wanted. In addition she has noted
inability to follow directions; i.e. she knows what she was
asked to do but cannot do it. She has noted that she
substitutes inappropriate words.

26. Sample
For the past several months she has had frontal dull
aching headache beginning in afternoon and relieved by
Aspirin. She denies nausea, vomiting or change with
Valsalva. However, the onset of headache has been a
distinct change.

27. Sample Medical History
General Data: Dela Cruz, Juan V., 56 year-old, male,
widower, Filipino, Roman Catholic, residing at 343 V.
Rama St., Cebu City, admitted for the first time at Vicente
Sotto Memorial Medical Center on July 20, 2008.
Chief Complaint: Inability to move both lower extremities

28. Sample Medical History
HPI: The present condition started one month prior to
admission as low back pain noted after lifting a heavy
object. The pain was deep, throbbing, waxing and waning,
mild to moderate (3-7/10), non-radiating, aggravated by
upright position, slightly relieved by rest, occurring round
the clock. He consulted a physician who prescribed him
Eperisone HCL 50mg 3x a day and Celecoxib 200mg once
daily, all for 5 days, and advised him three-day rest which
the patient complied religiously. These afforded gradual
relief for a week. Patient went back to work.
Three weeks PTA, low back pain recurred upon
rising from the bed. The pain had the same character but
more intense at night. He self-medicated with Eperisone
and Celecoxib for a wk which did not offer relief

29. Sample Medical History
nor aggravation.
Two weeks PTA, he had his back massaged in a
spa for two consecutive days. This made the pain more
severe (9/10) after he felt a snap during the session on the
second day. Other than increase in pain intensity, the pain
had the same character. He consulted a physician who
prescribed him Etoricoxib 120mg once daily and
Pregabalin 75mg at bed time. He complied with the
medication and rested for three days. There was relief of
pain. Patient went back to work.
One week PTA, patient noted weakness and
numbness of both feet and both legs but he was still able
to walk without support. He undergone reflexology for four

30. Sample Medical History
consecutive daily sessions which offered very minimal
relief.
Three days PTA, he noted weakness and
numbness of the whole lower extremities. He could not
walk without support. This was associated with
constipation and less frequent but non-painful urination.
Patient tolerated the condition and self-medicated with
Polynerve 500mg 2x day.
One day PTA, he developed inability to move both
lower extremities associated with inability to urinate.
Persistence of the symptoms prompted the patient to seek
consultation in this hospital.

31. Sample Medical History
PMH: Patient is not a known asthmatic, hypertensive and
diabetic. He has no history of hospitalization. He was
diagnosed to have Benign Prostatic Hypertrophy 6 months
PTA after three-month history of dribbling urination. He
was given medication for a month which provided relief. He
was cleared by their company physician cardiopulmonary-
wise in his latest annual medical check up.
Medications and Allergies: Patient is not on maintenance
medication. He has no known allergy to drugs and food.

32. Sample Medical History
ROS:
Integumentary: no skin discoloration, eruptions, pruritus,
scaling; no loss nor abnormal growth of hair; no nail clolor
changes, brittleness, ridging, pitting, curvature
Lymph nodes: no enlargement, pain, suppuration, draining
sinuses
Bones, Joints & Muscles: low back pain more nocturnal,
inability to move both lower limbs, wasting of lower limb
muscles by 25%; no joint swelling, stiffness
Hematopoetic: no pallor, no bleeding
Endocrine: no frequency in food intake, thirst, urination; no
intolerance to heat, no tremors

33. Sample Medical History
Allergic/Immunologic: no urticaria, hay fever, rhinitis
Head: no headache, vertigo, syncope, seizures
Eyes: far sighted, wearing eyeglasses for reading
Ears: no deafness, tinnitus, discharges
Nose: no discharge
Mouth: no soreness, gum swelling
Throat: no pain, hoarseness, sore throat, changes in voice
Neck: no swelling, limitation of motion
Breast: no lumps, enlargement, discharges
Respiratory: no pain, difficulty of breathing, cough
CV: no palpitation, chest pain, claudication

34. Sample Medical History
GI: loss of appetite, weight loss by 50% in a month’s time,
constipation in three months time, no abdominal pain, no
vomiting, no blood in the stool
GUT: dribbling urination for 6 months, inability to urinate for
one day, no change in urine color, no pain, no discharges,
no genital lesions
Nervous: numbness of both lower limbs, paralysis of the
lower limbs

35. Sample Medical History
Social History: He is the youngest among 3 siblings. He
was married for 32 years and became a widower 3 years
ago. Her wife died at 52 years-old from complications of
pulmonary tuberculosis. He has two children, all living,
ages 30 and 33, married, high school graduates; both are
apparently well. He finished high school and has been
working as a warehouse man, starting as a laborer and
now as a checker but also does some lifting when the
warehouse is undermanned. He receives 3,500 pesos
every payday. He is a smoker for 20-pack years starting at
16 years-old. He has never drank alcoholic beverages. He
does not eat vegetables; he prefers meat and fatty food.

36. Sample Medical History
Family History: Father died of lung cancer at age 52;
mother died from massive trauma in a vehicular accident
at age 48. Two other siblings are aged 60 and 58; both are
married and are living. The eldest is hypertensive with
maintenance medication and the other one is suffering
from dry cough with dyspnea for a year now but not yet
seen by a physician.

37. Sample Physical Examination
General Survey: Examined conscious, coherent,
cooperative, well-nourished, stretcher borne, not in acute
cardiopulmonary distress with the following vital signs:
BP = 110/80 mmHg
HR = 88/min
RR = 20/min
T = 36.7 oC
Anthropometrics:
Weight = 65kg
Height = 145cm

38. Sample Physical Examination
Skin: good turgor, no lesions
Head: normocephalic
Eyes: pinkish palpebral conjunctivae, aniceteric sclerae,
pupils equally reactive to light and accommodation
Ears: no lesions, no discharges, intact tympanic
membrane, non-tender mastoid
Nose: no discharges, pinkish conchae
Throat: no tonsilopharyngeal congestion
Neck: supple
Breast: no lesions, no discharges, non-tender
Chest: equal chest expansion, (-) Litten’s sign, (+) tactile
fremitus (B), resonant, clear breath sounds

39. Sample Physical Examination
Heart: PMI at 5th ICS L MCL, CAD within normal limits,
distinct heart sounds, no murmurs
Abdomen: distended bladder, (+) Beevor’s sign
normoactive bowel sounds, typmpanitic, no
organomegaly
GUT: no lesions, no discharges, (-) kidney punch
Extremities: no deformities, all joints of the UE full actively
done, all joints of the LE full passively done,
bounding peripheral pulses, good capillary
refill
Neurological Exam:
Cerebrum: conscious, oriented to TPP, GCS 15

40. Sample Physical Examination
CN I: distinguishes scent of mango from guava
CN II: can read newspaper print w/o reading glasses
CN III, IV, VI: full EOM movement
CN V: (+) corneal reflex, intact sensory maxilla, good
masseteric tone
CN VII: no facial asymmetry
CN VIII: can locate source of sound
CN IX, X: (+) gag reflex
CN XI: (+) shoulder shrug (B)
CN XII: tongue at midline
Sensory: C2 – L1 graded 2 bilaterally
L2 - S5 graded 1 bilaterally

41. Sample Physical Examination
Motor: BUE 5/5, BLE 0/5
DTRs: C567 ++ (B); L4-5S1 +++ (B)
Superficial Reflexes: (+) cremasteric reflex
Pathologic Reflexes: (+) Babinski, (+) ankle clonus
Sacrals: (+) anal wink
Cerebellum: (-) nystagmus, (-) dysdiadochokinesia, (-)
astereognosis

42. Format for Med Hx and PE
General Data:
Chief Complaint:
History of Present Illness:
Past Medical History:
Medication and Allergies:
Review of Systems: (symptoms per system)
>Integument
> Lymph nodes
> Bone, joints and muscles
> Hematopoetic system
> Endocrine system
> Allergic and immunologic history
> HEENMT
> Neck

43. Format for Med Hx and PE
> Breast
> Respiratory system
> CV system
> GI system
> GUT system
> Nervous system
> Psychiatric history
> Developmental milestones (for pediatrics)
Physical Exam:
> General Survey
> Anthropometric Data (for pediatrics)
> Skin
> HEENT
> Neck
> Breast
> Chest/Lungs
> Heart

44. Format for Med Hx and PE
> Abdomen
> Extremities (includes Goniometry)
> Genitourinary tract
> Neurological Exam (for neuro cases)
- Cerebrum
- Cranial Nerves I-XII
- MMT
- Sensory
- DTRs
- Pathologic reflexes
- Primitive reflexes (for pediatric neuro)
- Cerebellum
> Special tests

45. Format for Special Test
Test Description Reliability/
Validity Tests
Comments
Phalen’s test The patient is asked to hold
the forearms vertically and to
allow both hands to drop into
flexion at the wrist for
approximately one minute.
Compression by this
maneuver causes almost
immediate aggravation of the
numbness and paresthesia in
the fingers.
Gerr and Letz:
Sensitivity 75%
Gellman et al:
Sensitivity 71%
Specificity 80%
Phalen:
Sensitivity 80%
Specificity 20%
When compared with
EMG
As SNCV decreases,
the % of patients with
(+) results increases
from 20% at 50 m/s to
78% at less than 30
m/s
N.B.: Attach as appendices the full paper.