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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