CPH LAB - Lesson 1: Medical History Taking

• Patient History

  • It can be subjective and objective
  • Subjective: What the patient tells you

  Objective: A physician/professional observation and vital signs
• How to Establish a Doctor-Patient Relationship

  1. Set appropriate place, manner, and choice of words
  2. Demonstrate genuineness and altruism
  3. Be truthful about who you are personally and professionally
  4. Address patient appropriately
  5. Communicate your understanding and appreciation
• Medical History

  • A record of past events and situations or conditions that are or may be relevant not only to the patient’s current but also to future health
  • This information contains:

  1. Biographic data
  2. CC - Chief Complaint
  3. HPI - History of Present Illness
  4. Past medical history
  5. Family health history
  6. Lifestyle and health practices
• Part of taking medical history is to interview the patient, this is to establish a rapport and a trusting relationship and to gather information about the client’s general well-being. As a healthcare professional, one should keep in mind the following when interviewing a patient:

  • Introduction
  • Explanation of the procedure
  • Confidentiality
  • Record of the date
  • Time of examination

  The healthcare professional can proceed to the following basic questions when all of these are established.
• What are the components of an interview?

  Opening, information gathering, and closing
• Opening

  • Greet the patient and address appropriately
  • Introduce yourself and your role in the medical team
  • Get informed consent from the patient (at least verbal)
  • Explanation of the stages of testing, the testers, and the benefits
  • Remember: Patients have a right to refuse
• 1. Information Gathering

  • Encourage the patient to tell the story
  • Begin with an open-ended question which allows the patient to state the problem in their own words.
  • 2 Types of Communication: Verbal and Non-Verbal
  • Must maintain eye contact
  • You must not interrupt a patient when telling a story
• 1. Closing

  • Summary of what the patient told (repeat what they said)
  • Ask them if they have questions
  • Thank them for their time
• What are the components of medical history in Primary History?

  Demographics, Chief Complaint, and History of Present Illness
• 1. Demographics

  • Age, gender, ethnic group, etc.
• Chief Complaint

  • Any symptoms or signs
  • What is the problem? / Ano ang dahilan ng pagbisita?
  • Note the patient’s own words; in writing, in verbatim, word-for-word 
  • Note the associated complaints (Ex.: Primary CC is toothache but the pain caused a headache)
  • Can be:
  • An abnormal laboratory results in an otherwise asymptomatic patient
  • A continuation of the previous/current treatment cycle
  • A routine executive check-up for clearance for job purposes
• History of Present Illness

  • The main part of history taking
  • Full details of the history of the main complaint; recounts the events
  • Identifies the organ system that is primarily involved in chief complaint
  • Progression ‘till examination
• Manner of Writing HPI

  • Chronological order
  • Events starting from previous well condition to worsening condition
  • PTA = Prior to admission
  • PTC = Prior to consultation
  • OLD CARTS
  • Onset: sudden or gradual
  • Location
  • Duration: Gaano na katagal nangyayari?
  • Character: Makati ba? Masakit ba? Etc.
  • Aggravating factors: Ano nag-tritrigger?
  • Relieving factors: Anong iniinom na gamot for the pain?
  • Temporal factors: Madalas ba nararamdaman o paminsan-minsan lang?
  • Severity of symptoms: Rate the pain
• Signs vs Symptoms

  • Signs = directly observed by physician; Physical examination
  • Symptoms = as described by the patient; elaborated in Review of Systems
• What are the components of medical history in Secondary History?

  Review of Systems
• 1. Review of Systems

  • Expand the primary history
  • Includes associated symptoms and other commodities
  • Entails a rundown of questions involving all other systems not dealt with API
  • Should start within time frame of HPI

  *Denies = did not experience the symptoms
• Questions specific to the Body System (pt.1)

  1. Digestive 

  • Appetite = increased or decreased
  • Diet (what type of foods do you eat)
  • Weight = gain or loss
  • Dysphagia or difficulty in swallowing
  • Nausea/vomiting 
  • Distention or pain when palpating stomach area
  • Stool color has melena (black) or hematochezia (red)

  1. Respiratory

  • Cough = dry or wet
  • Hemoptysis or coughing up blood
  • Dyspnea or difficulty in breathing
  • Chest pain

  1. Cardiovascular

  • Breathlessness (palpitation)
  • Cardiac pain
• Questions specific to the Body System (pt. 2)

  1. Uro-genital 

  • Micturition: dysuria, polyuria/nocturia
  • Pain while urinating
  • Urine color

  1. Musculoskeletal

  • Rubor (redness)
  • Tumor (swelling) - pain when being touched
  • Dolor (pain)
  • Calor (heat)
  • Loss of function

  1. Nervous

  • Mental state: calm, nervous
  • Peripheral nerve: experiences prickly sensation in hands and feet (paresthesia)
• What are the components of medical history in Tertiary History?

  Family History, Past Medical History, and Personal and Social History
• Family History

  • Documents health or genetic disorders in the patient’s immediate and extended family
  • Helpful in determining patterns of disease and causes of death
  • Pedigree and genogram
  • TB Exposure = Non-hereditary but must be included in family history
• Past Medical History

  • May be relevant to the patient’s present medical problem (ex.: childhood illness, allergies, operations, accidents, etc.)
• Past Medical History for FEMALE Patients

  MIDAS (Gynecologic History)

  • Menarche - first occurrence of menstruation
  • Interval
  • Duration
  • Amount
  • Symptoms

  GPFPAL (Obstetric History)

  • Gravidity - total number of pregnancies regardless of outcomes
  • Parity - total number of times a female has given birth to a fetus with a gestational age of 24 weeks old, whether viable or non-viable
  • Full Term - 39 weeks above
  • Premature
  • Abortion
  • Alive
• Personal and Social History

  • life style of patients (modifiable & non-modifiable)
  • smoking
  • # pack per day x # of years
  • 1 pack = 20 yrs
  • 10 sticks/20 yrs x 10 yrs = 5 pack years
• Personal and Social History (pt. 2)

  • Alcohol Consumption
  • 1 standard drink = 10-15g ethanol
  • 12 oz beer
  • 4 oz non-fortified beer
  • 1.5 oz of 80 proof beverage
  • Recommended:
  • MALE = 3 per day
  • FEMALE = 2 per day
  • Medication History
  • self-described/OTC
  • Doctor prescribed
  • Herbal medications
  • Illegal substance abuse
  • Immunizations
  • Sexual History