THE MEDICAL HISTORY by cFpU4xbV

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									                                THE MEDICAL HISTORY

                                          Content Guide

The aim of obtaining the patients medical history is to adequately define the nature and
history of the problems. Below are listed the areas of enquiry you would follow and are
presented in a logical order. This is not necessarily the order the patient will tell you them nor
necessarily the order in which you would write them up. Note that as well as the biomedical
information a history includes psychosocial information and the patient’s view of the illness.

A. History of Presenting Complaint (HPC)
        1. Characteristics of symptoms - for example in the case of pain the following
           information is required:
                     Site
                     Onset
                     Character
                     Radiation
                     Alleviation
                     Time (duration/past experience of symptoms)
                     Exacerbation
                     Severity

           2. Context - what were the circumstances of the onset of symptoms (physical,
              social, psychological)
           3. Response to symptoms - what the patient has done about symptom.
           4. Consequences - what do symptoms interfere with (physical, social,
              psychological)
           5. Patient’s understanding & own views about cause, implications and treatment.
              What have they been told.
           6. Concerns and worries

B. Review of Systems (ROS)
Brief structured review of body systems which were not discussed in the HPC

C. Past Medical History (PMH)
        1. Medical
        2. Surgical
        3. Obstetric
        4. Allergies
        5. Medication

D. Family History (FH)
      1.Current health of parents, siblings, children
      2.History of significant illnesses
      3.Death: dates & age at death.

E. Social History (SH)
        1. Home environment -
                living arrangements
                who is resident
                nature of relationships
        2.   Support/secondary gains:        how family and friends have responded to illness
        3.   Sexual function:       any difficulties
        4.   Important losses:      deaths, separation, divorce
        5.   Work history/job satisfaction
        6.   Other areas: Finance/interests
        7.   Nutrition, diet eg dietary beliefs & meal patterns
        8.   Smoking, alcohol, drug use

F. Mental Status Evaluation * (Including past psychiatric history, mood changes, changes in
   sleep/appetite, memory or cognitive changes, disturbing thoughts or ideas).

G. Treatment History (TH)

 (Mental Status Evaluation would normally be made after Social History. You should be
  aware of this fact and it is listed for completeness but you are not expected to undertake it at
  this stage in your course.)

Problem Orientated Medical Records
The purpose of Problem Orientated Medical Records (POMR) is to structure the medical
case history to make it easier to interpret the relevant clinical information and to provide a
framework for planning diagnostic tests and therapeutic procedures. It also will help to
remind you, the clinician, what is troubling your patient and how such problems may be
resolved.
The emphasis of POMR is the compilation of a list of problems on the basis of clinical
findings (history and examination). The diagnosis or diagnoses, will only be made if all
problems are considered.
If used appropriately, POMR will help you to make decisions about patient care: it was
also provide a structure which is very helpful for medical audit.
How to problem orientate a medical record:
1. Problem listing. Review your patient’s history and examination findings and list all of
the apparent problems (including social/domestic ones). You should list the problems in
what you consider to be an order of priority with the presenting medical problem(s) at the
top – P1, P2, P3 etc. Problems may be categorised into ‘active’ or current problems and
‘inactive’ or past problems – it is important when you do this to recognise possible
associations between past problems and current ones. For example, rheumatic fever as a
child may be the explanation for the development of cardiac failure as an adult. In this
circumstance, the presenting problem of breathlessness (P1) should be listed as follows:
P1 Breathlessness – past history of rheumatic heart disease. All the problems should be
listed irrespective of whether they are currently active or inactive if you consider they may
have a bearing on the patient’s well being. For example, if your patient with
breathlessness and a past history of rheumatic heart disease has also been treated for
peptic ulcer, this should be listed as a problem i.e. P2. The significance of this will be if
the patient needs anticoagulation for mitral valve disease – endoscopy before starting
warfarin to confirm inactivity of the ulcer will be prudent.
2. Structuring each problem. Having listed the problems, you should start to
formulate an initial plan of investigation and possible treatment. This requires you to think
about a possible diagnosis or diagnoses which best fit the clinical findings. It is useful at
this stage to analyse each of the patient’s main problems in more detail by using the
principle of SOAPI. This stands for Subjective, Objective Assessment, Plan and (patient)
Information – in other words, all the factors you will be considering for making a
diagnosis. If we take out patient with breathlessness and apply SOAPI:
P1 Breathlessness – past history of rheumatic fever
S-        Breathlessness
O-       History and clinical signs suggest cardiac failure. Raised JVP, bilateral ankle
         oedema and basal crepitations. In addition, there is a pansystolic murmur at the
         apex and atrial fibrillation.
A-        Biventricular failure possibly secondary to rheumatic valvular disease.
P-        ECG, CXR (if not already done) blood cultures and an echocardiogram.
I-       ‘Your breathlessness results from congestion on the lungs due to some heart
failure’.
P2 Past history of peptic ulcer disease
S-    No complaints
O-    No symptoms or signs
A-    Probably now resolved
P-    Needs endoscopy in view of anticoagulation.
I-    Informed about endoscopic procedure.
3. Progress notes. It is useful to follow the patient’s progress during admission by
keeping progress notes in a similar structured fashion, addressing each of the patient’s
active problems in turn.
Although POMR appears unwieldy at first sight, you will find not only a useful way of
structuring your case histories but also a practical method to enable you to use all the
important clinical information which you have gathered.

								
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