Clinical Medicine

Physical Diagnosis (History taking)

Dra. Divina Fundimera / September 13, 2021 1stSemester
I. HISTORY TAKING RESPONSES OF INTERVIEWER:
• Specific objectives • To encourage free expression but nor to let the patient wander
A. Interviewing/ Communication Skills • Encourage the patient to say more to
B. Data gathering medical history continue with the story
FACILITATION
C. Writing/Organizing skills • “Uh-uh”, “go on”, “yes”, “continue” or
TYPES OF QUESTIONS USE DURING THE INTERVIEW: simply nodding
1. Open-ended questions • Gives patient time to think to organize
• Ask for narrative information what he wants to say w/o being
• Encourage patient to describes events as he perceives it. interrupted
SILENCE
• “What brought you to the hospital?” • Gives also the examiner the chance to
• “Tell me why you come here today” observe the patient especially for
nonverbal cues
• “What are you feeling about this?”
• Repeat or echoes part of what the
• Is there anything more you need to talk about”?
patient have said to encourage more
details
LECTURE NOTES REFLECTION • Focuses more attention or emphasis on
• You ask about your patient, what the problem, so you should ask specific phrase and helps the person
questions continue ion his own way to give you
• Hayaan mo yung patient sagutin niya kung ano yung more details
nararamdaman niya; ano yung Nakita niya sa sarili niya • Recognizes a feeling expressed by the
patient with or without words, which
2. Closed-ended questions embarrassing or shameful, and
responding to them in a way which
• Ask for specific details or information
EMPATHY shows understanding and acceptance
• Elicit a short one or two-word answer a “yes” or “no” or forced
• Makes patient feel secure and
choice
encourage them to continue
• Ask to fill in any details, patient may have omitted after the
• “I understand”, I’m sorry”
narration
• “This must be very hard for you”
• When you need many specific facts such as when asking about
health problems or during the review of systems • Used when the person’s choice of words
“How long ago did that happen?” is ambiguous or confusing
CLARIFICATION
“Where does it hurt” • “What do you mean?
• “Tell me what you mean by…”
LECTURE NOTES • Do not hesitate to discuss a patient ‘s
• “May lagnat ka ba? Kailan pa yan nagumpisa? disturbing behavior
• “Masaki ba? Nasaan ang masakit? • Point out to patient a discrepancy or
CONFRONTATION inconsistencies in his words or behavior
• Patient:“Nagkaroon lang ako ng sipon, madalas ako nabahing for verification or to bring out certain
tapos hinihingal na po ako, parang may nakaipit” feelings in the open
o Ask if the patient is asthmatic, or if there is already a difficulty • “You look sad”, “You sound angry”
of breathing before and when was that • Sharing factual and objective
information to explain something
3. Leading questions EXPLANATION • The reason you cannot or drink before
• Very risky and must be avoided your blood test is that the food or drink
• Include the answer in the question or suggest your desired can affect the test result
response • Repeat what you have heard to confirm
• “You do not have blood on your stool, don’t you?” INTERPRETATION
the patient’s meaning
• “It didn’t happen too often, did it?” • Prioritize questioning of info relevant to patients’ problem
• Use proper terminology and fluent understandable speech
LECTURE NOTES • Display proper professional attitude in relating with patients and
• “Wala ka naman poopoo sa dumi mo DIBA?” relatives
• Never ask the patient’s this kind of questions:
o Yun bang sakit ng tiyan mo parang pumipiga; Yun bang sakit COMPONENTS OF MEDICAL INTERVIEW
ng ulo mo gusting sumabog o parang napintig • 3 parts:
o Opening portion
• Example, a patient complained of excessive coughing “Masakit ang
o Information gathering proper
lalamuna ko, ubo ubo ako parati, ang dami ko ng ininom na cough o Closing or concluding part
medicine di pa din nawawala” A. Opening portion
o Never tell the patient “Di naman palagi yan DIBA, okay lang • Greet the patient and address appropriately using
yan, gagaling din yan” Mr./Mrs./Ms, or his/he title. NOT BY FIRST NAME
o Kuya/Ate/; Mam/Sir
o If there are other people present in the room,
acknowledge and greet them well
• Shake hands with the patient and with other people in the
room if appropriate
• Introduce yourself and explain your role and purpose of visit
• Provide clear statement of the purpose of interview and
importance of visit

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 • Ensure privacy. Place should be private, comfortable and safe o How often you punctuate speech with “ah” and “you
both for you and the pt. know” (some patients are irritated by this)
• Put the patient at ease. Attend to the patient’s comfort first. • Be a good listener and observer
Ask him to assume position comfortable for him. Avoid o Your nonverbal attitudes compliment your listening
distractions. o Can be expressive but avoid extremes of reaction
• Express how long the history and Physical examination will o Can nod in agreement
take: o Eye contact should be assured and comfortable
o What will be done? How? When? Expected of the o Body language should show that you are really with the
patient? patient
o Right of the patient to refuse w/o adverse • Behavior
consequences o You must be calm and unhurried
o Alternatives may be done o Avoid reactions that block communication as
• Explain the need to take notes and ask if this is acceptable o Disbelief (di ka naniniwala sa patient mo)
o Assure the patient that everything that is written o Embarrassment
is confidential and will only be use for their sake o Impatience
o Take notes as sparingly as possible o Boredom
• Get informed consent from the patient o Criticize
o Belittle
• Speak with respect
B. Information gathering proper • Personal appearance
o Help build the patient trust
KEYPOINTS
o Cleanliness
• Encourage the patient to tell his story. Do not interrupt o Neatness
• Begin with an open-ended question. This will allow the o Appropriate dress
patient to state his problem in his own words o Name tag/ name plate/ ID
o Use concise easy to understand questions and REMINDERS FOR GOOD COMMUNICATION
comments
• Knock before entering the room
o Avoid multiple, jargon, and leading questions
• Address first the patient. Okay to shake hands
• Maintain a positive atmosphere, warm manner and good
eye contact • Meet and acknowledge others in the room
COURTESY
• Establish a narrative thread • Ensure CONFIDENTIALITY
o Establish dates and logical sequence of events • Make notes sparingly
o Let the patient tell his story without interrupting • Respect the need for modesty
o Listen carefully and attentively
o Follow significant leads • Ensure physical comfort for all (take note kung
o Give time for the patient to think before answering ano na nararamdaman ng patient mo.
• Expound on the problem/s appropriately Ngaiinterview ka pa, masama na nga
COMFORT pakiramdam)
o Ask and verify problem
o Restate the content (paraphrase patient’s answers) • Maintain privacy
o Clarify and check accuracy • Ensure good lighting and quite environment
• Be alert and responsive to verbal and nonverbal cues •
regarding patient comfort/discomfort • Maintain good eye contact
o Be sensitive about body language, speech, facial • Watch your language
expression and affect of the patient. Check if the cues
• Do not dominate the discussion listen alertly
are appropriate
• Let the patient order priorities if several issues
• Facilitate the patient’s disclosure both verbally and non-
are raised
verbally until all major concern are expressed
o Verbally: repetition, paraphrasing, interpretation and • Consider first what the patient has to say before
vocal cues (intonation, and volume changes) looking at previous laboratory results
o Non-verbally: facial expression, eyebrow movement, • Avoid leading or direct questions at first Open-
posture, body position and movement as nodding ended questions are better for starters. Let
• Encourage the patient to be relevant CONNECTION specifics evolve from these
o “Let us go back to what you are saying about your • Avoid being JUDGEMENTAL
epigastric pain. Let us not talk about epigastric pain of • Respect silence. Pauses can be productive
your neighbor • Be flexible. Rigidity limits the potential of an
• After sufficient data base has been collected, ask close- interview
ended questions • Seek clues to problems from the patient’s
o “Was it crampy or colicky pain”? verbal behaviors and body language
o “Did you fall when you feel dizzy”? (nahulog tsaka • Look for hidden concerns underlying the Chief
nahilo -trauma; nahilo bago nahulog – cause ang hilo complaint
ng pagkahulog) • Problems can have multiple causes. Do no leap
• Progress from one section to another using transitional to one cause quickly
statements • Ask patient or you to summarize the discussion.
o “We have finished asking about your major concern. There should be clear understanding.
Let us now talk about your past history” Uncertainty should be eased
YOU AS INTERVIEWER • Allow possibility of more discussion with
• Examine your habits and modify them when necessary another open-ended question, “Anything else
o Stiff formality may inhibit the patient CONFIRMATION
you want to bring up”
o Too-casual attitudes may fail to instill confidence (wag • If there is question that you cannot answer
masiyadong friendly, baka hindi maniwala sayo ang immediately, say so (titignan ko po at pag
patient mo) aaralan ko po kung ano talaga ang problema, sa
o Do not be careless with words ngayon po eto lang po ang nakikita ko” But
o How you ask questions make sure to follow it up later if possible
o How fast you talk
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 •If you seem to have made a mistake, do not
dissemble and make effort to repair it. Most
patient will respect it. (“May lumabas po kasi na
bagong resulta, kay ayung unang diagnosis natin
parang iba sa Nakita natin sa ngayon”). Explain
everything but do not dissemble it. Make sure
not to do much mistake!
QUESTIONS TO CONSIDER – American Board of Internal Medicine
• How would you like to be addressed?
• How are you feeling today?
• What can I do for you today?
• What do you think is causing your symptoms?
• What is your understanding of your Dx? Its importance? Its needs
for management?
• How do you feel about your illness? Frightened? Threatened?
C. Closing or concluding part
CLOSING THE INTERVIEW
• Summarize what the patients has told you. Ask if your summary is
accurate
• Ask patient if he would like to add anything
• Encourage the patient to ask questions. Do nor avoid answering
additional questions as clearly and honestly as possible
• Thank the patient. State appreciation for the patient’s effort
ENDING THE INTERVIEW
• Give the patient the chance to ask questions
• Inform the patient about the plans
• Summarize what has transpired during the interview
• Thank the patient for the interview and information shared
REMINDERS:
• Patient’s history is a privileged communication
• The patient expects and the law demands that the dialogue is
CONFIDENTIAL
• It is physician’s duty and moral obligation to observe and maintain
patient’s right to privacy
• Distortion of the truth sometimes “seems appropriate” under the
guise of what is best for the patient
• Family members sometimes encourage concealment of the truth
in a misguided effort to shield or protect the patient from difficult
issue
• As, STUDENT, you are not to provide information about the
aspects of care beyond your responsibility.
• The privilege of providing information to patients belong to the:
o Attending Physician
o Senior resident Physician Staff
AVOID
• Providing false assurance or reassurance by trivializing the anxiety
or fear of the patient
• Giving advice that shifts the accountability for decision-making
from patient to you.
• Using authority that promotes patient’s dependency and inferiority
• Interrupting patient unnecessarily
• Talking too much
WRITING/ORGANIZING SKILLS
• Differentiate between irrelevant and relevant data
• Organize data in logical sequence
• Write data accurately and legibly using correct grammatical cons
of phrases/sentences
• Write the prescribe format of medical history
II. MEDICAL HISTORY
• Define- parts of the medical history
• Enumerate the proper and logical sequence of the parts of the
medical history
• Define the scope of the history sufficient for a given complaint
• Elicit concise med history following a logical and organized
sequence of interview
Importance of History Taking
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1. Facilitate gathering of relevant information which provide the basis on
the appropriate diagnostic workup and therapeutic options
2. Establish a good patient-physician relationship. Gain the trust of the
patient.
Sources of History
• Primary History
o Information regarding the current medical concern that
brought the patient to the hospital or clinic – Chief
Complaint and History of the Present Illness
• Secondary History
o Includes all the accompanying symptoms that may be
related or co-exist with the present medical problems –
Review of the Systems
o Just the accompanying symptoms nit the main problem
of the patient
• Tertiary History
o Includes patient’s past history, family, social and
personal that will be relevant on the overall assessment
of the patient
Types of History
1. Complete history
o Addresses as many details about the patient’s
complaint as possible
2. Inventory history
o Entails only the major points w/o going into details to
have a feel of situation
o Eventually completed in subsequent session
o Salient feature of the patient, the major points. This can
be the pertinent positive or pertinent negative
3. Problem or focused history
o Taken when the problem is acute or possible life-
threatening requiring immediate attention as in ER
settings
4. Interim or Interval history
o Center on present problem that occurred since the last
encounter (Ex. a week ago, or one week ago for
shortness of breath) with the patient either in outpatient
setting or previous admission
o It should always be complemented by the patient’s
previous record
o For example, your patient having a chronic condition
like dialysis and the patient has been coming in for
repeated episodes of difficulty in breathing or repeated
persistent edema that requires edema you may use this
interim or interval history.
DOKKAEBI
 residing in (address) was admitted for the 3rd time at
LECTURE NOTES FUMC last September 3, 2021
• The usual sequence of gathering data is History Taking and then 2. CHIEF COMPLAINT
Physical examination. • Principal reason/s for seeking consult, or admission
• History taking is observed when the time is not a factor such as • It can be:
in outpatient (OPD) o Symptoms – It is an objective finding; what the
• Reliable source of information called Informant is required patient feels or perceive
o Patient o Signs – what is shown in PE or Physical findings,
o Relatives findings of the examiner
o Accompanying person- sumugod sa hospital) o Example:
• The more accurate information will be retrieved from the Symptoms – Palpitation
patient as the informant Signs – tachycardia
• Difficult situations wherein limited history taking, and focused Edema can be a sign as well as symptom
PE are performed (sign once you examine the px you will
o Comatose patient with relatives who did not witness see the Edema
o Diagnostic Procedure – patient came in for
what transpired
endoscopy (CC)
o Comatose patient without any resource person
o Treatment- Patient came in for dialysis
o Uncooperative Patient chemotherapy, blood transfusion- (CC)
o Irritable patient o Executive checkup – Annual checkup only - CC
o Communication or language barrier o Clearance for Job Purposes CC for clearance
only
Format of Hx Taking • Can be 1 or 2 complaints (Head and chest)
• Do not use diagnosis or names of disease
o For example: The patient came in: “Doc, meron po
akong influenza, penuemonia.” This is not a CC
because that is a diagnosis)
• It is written as words or phrases – NOT COMPLETE
SENTENCES
• Duration of complaint maybe mentioned (Ex. 2 weeks fever; 2
weeks prior to consult the patient starting to have fever)
• If more than one complaint, write each complaint in separate
line (if not related except cough and cold which can be written
in one line)
• Appropriate questions should be used like:
o “What brings to the hospital?”
o “Tell me about your problem”
• Record CC as nearly as possible in patient’s own word
o Ex. CC fever for 2 weeks
• You may use appropriate medical term or wards that are
1. General data (Paragraph Form) reflective of true chief complaint after a thorough clarification
2. Chief Complaint: 1 or 2 symptoms from source or patient
3. History of Present Illness (HPI) • It provides a key word to formulate the initial impression
4. Past Medical History • It will guide you to a focused medical History and to a logical
5. Family history initial Diagnosis and differential Diagnosis
6. Personal and Social History • Example:
7. Obstetrical and Gynecological History (Female only) o According to pt: I cannot catch my breath
8. Review of Systems o Doctors: Dyspnea
9. Physical Examination o Most likely organ involved: Respiratory
o General Survey o Another organ to consider: CVS
o Vital Signs • Manner of asking CC
o Regional Examinations o Use open-ended question to extract the reason for
1. GENERAL DATA medical encounter
• Should be in the Paragraph Form o Must be precise as possible
• Contain the necessary information that will establish the o Ex. Epigastric pain vs abdominal pain
identity of the patient The more nonspecific the CC is, the
o Name harder is it for you to do a focused
o Age (incoherent/comatose)
o Civil status • Other sources of chief complaint
o Sex o The source can be from someone other than the
o Occupation patient:
o Nationality Relatives
o Religion Caregiver
o Date and Place of Birth Non-related accompanying person
o Present Residence (Address) o This is when patient cannot verbalize or is not
o No. of Admission in the hospital reliable (incoherent/comatose)
o Date of Admission • Chief Complaint
• Indicate the source of information (informant) o Provide a key word to formulate the initial
• Indicate the accuracy of the information impression
• Example: o It will guide you to a focused medical history and a
o Juan Dela Cruz, a 24-year-old, single male Filipino logical initial diagnosis and differential diagnosis
student, born on January 20,1990 in Samar and presently
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 • Example:
o CC: I cannot catch my breath
o MD: Dyspnea
o Organ involved: Respiratory
o Another organ to consider: CVS
3. HISTORY OF PRESENT ILLNESS (HPI)
• Recounts the events w/c characterize the nature of the
patient’s main problem
• Most important part of medical history
• Written in narrative form
• Should be chronological, as symptoms comes
• It is not necessarily the first symptom
• Example:
o CC: difficulty of breathing which was experienced
few hours PTA
o The present illness started 4 weeks PTA, when the
patient developed productive cough. 2 weeks PTA,
the patient developed fever that can only be
observed during nighttime. 1 week PTA, there was
an associated chest pain every time the patient will
cough. Few hours PTA, the patient developed
difficulty of breathing
I. Onset of illness
• Start from the onset of the first symptom up to the time of
consultation or admission in the hospital
• Manner of onset of each symptom:
o Gradual or sudden
o Insidious
• Not necessarily the CC
• The date of reference as to the onset of each symptom can be
described according to the:
o Number of minutes, hours, days, weeks, months,
years, etc… before the date of consultation or
admission
o Do not put the date on the HPI, however you need to
put how many days, how many hours, weeks, prior to
admission…
• Example:
o Few hours prior to admission (PTA)
o 4 months PTA
o 5 days prior to consultation (PTC)
o 1 year PTC
II. All Symptoms felt by the patient in Chronological
Sequence
• Symptoms which appeared before the CC
• Symptoms that appeared with the CC
• Symptoms that appeared after the CC
• Symptoms experienced by patient related to the CC
• Note for the absence by symptoms that may have diagnostic
significance (Negative Pertinent Information)
III. Analysis of Each Symptom
• Detailed description of each symptom
• PQRST of PAIN
Precipitating/aggravating/palliative/relieving factors
• Precipitating Factors: What brings out the symptoms
(Ano nauna, bakit siya nagkaroon ng pain)
• Aggravating Factors: What makes the symptoms worst?
(Bakit lalo sumakit, ano ang ginawa)
P • Palliative Factors: What relieve the symptom
• Consider the effect/relationship of the ff:
o Emotional stress: anger, anxiety, excitement
o Physical Stress
o Food, diet, alcohol, drugs
o Environmental factors
Quality/Character/Type of symptom
• What is symptom like?
Q • Example: Pain: sharp, throbbing, pressing, colicky,
crampy, burning, gnawing dull, heaviness
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Region/Location; radiation of symptom
R • Ask the patient to point out the specific location of pain
and where pain radiates
Severity/Intensity of symptom and its progression
• Usually assessed by how it affects the patient’s
activities, lifestyle, personal and interpersonal
relationship
S • Describe symptom as mild, moderate, severe
• Progress of each symptom as improving, worsening,
unchanged
• May report in pain scale (7/10)
Time Relationships
• Onset of each symptom prior to date of
admission/consultation
• Duration of Symptoms: How long does the symptom
T last?
• Periodicity and frequency of Symptoms:
o Recurrent: every 4 days, 3x/day
o Continuous: no free periods
Example: The patient had sudden constricting 8/10 substernal chest
pain radiating to the left shoulder lasting for approximately 30
minutes after climbing 2 flight stairs, not relieved by intake of
isosorbide dinitrate (Isordil) 5mg/tab one tablet taken sublingually. It
was accompanied by cold clammy perspiration and dizziness.
“OLD CARTS”
O -Onset
L- Location
D- Duration
C-Character
A-Aggravating/Associated
R-Relieving Factors
T-Temporal Factors (sudden, gradual, acute, chronic,
intermittent, continuous)
S- Severity (bearable, progressive, grade scale 1-10)
COMMON SYMPTOMS
• Chest pain
• Abdominal pain
PAIN • Headache
• Backpain =Upper/Lower
• Joint pain
• Documented (uses thermometer) “how high is
the fever”/Undocumented (by touch) “how did
you know that you have fever”
• Character
o Intermittent- temp falls to normal each
day with exaggeration of the normal
rhythm
o Remittent- temp falls each day but does
not return to normal
FEVER o Continuous -constant, hindi bumababa
o Biphasic – early elevation in body temp
followed by a latter one
o Step Ladder- fever rises one day, falls
the subsequent morning
• Low Grade, High Grade
• Example: 2 weeks PTA, the patient developed
undocumented low-grade fever usually noted
at night, it is intermittent in character
• Projectile/Non-projectile
o Projectile – without any effort, gastric
content is released from the mouth.
Normal na pagsusuka
VOMITTING o Non-Projectile- with retching, effort is
exerted to release the gastric content.
Pilit na pagsusuka
• Frequency- how many episodes per day
• Timing- near meals/after food intake
DOKKAEBI
 • Composition of Vomitous
o Digested/undigested
o Bilous, w/blood
o Color
• Amount (cup) per bout
• Example: Px deceloped non-projectile
vomiting, 4-5x per day, usually noted after food
intake, and the vomitous is bile-stained
composed of digested food with no blood,
amounting to 1 cup per bout
• Frequency – how many times per day
• Character of Stool:
o Water, soft
o Mucoid, blood-streaked
LOOSE
• Color/Odor
BOWEL
• Amount (cup,tbsp) per bout
MOVEMENT
• Example: 3 days PTA, the px developed loose
bowel movement more than 10x per day, stool
is described as watery, non -blood-streaked
and non-mucoid, amounting to 1 cup per bout
• Activity that produces it/ at rest
• Precipitating factor
• What can relieve it
• Uncomfortable awareness of breathing, “can’t
get enough air”, air doesn’t go all the way
• Other manifestation of respiratory difficulty:
o Easy fatigability
the usual activity that the patient
does can’t be performed by the
patient anymore without having a
hard time to breathe
o Orthopnea
Dyspnea in supine. Difficulty in
supine position but once the
patient sit up or his head is
DYSPNEA
elevated the difficulty of breathing
is relieved
Frank manifestation of Congestive
Heart Failure
Ex. Asthma and COPD
o Paroxysmal Nocturnal Dyspnea (PND)
Usually gets woken up at night
due to difficulty of breathing but
once they sit up, the dyspnea is
relieved
Initial manifestation of Congestive
Heart Failure
o Platypnea
Even at rest there is difficulty of
breathing
• Onset: sudden, gradual
• Duration: days, weeks, months, years
• Nature of Cough:
o Dry, moist, wet, hoarse, hacking,
whooping, bubbling
COUGH o Productive/Nonproductive
o Sputum: color, amount, blood streaked,
purulent, foul odor
o Pattern: occasional, regular, paroxysmal,
precipitated by activities/exercise/weather
change, pollutant exposure
• Clarification:
o Categorize the symptom to its
corresponding medical term
BODY Example: “I feel weak”
WEAKNESS Paralysis – weakness of more
muscle group
Malaise- generalized weakness
Myalgia- Muscle pain
• Unstable Gait: Disequilibrium
DIZINESS
• Whirling Sensation: Vertigo
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• Usually means faintness ir vertigo (sense of
self or environmental movement)
• Inflammation (Pain)
SWELLING
• Edema (No pain)
IV. Consultations Made, Medications Taken
• Dosage, generic name, how long taken, effects of treatment
• If consultation is made for the present illness and there are
laboratories done:
o Indicate what laboratories or procedure done
o Results of that lab/procedures
• Example: 1 month PTA, the patient has productive cough and
sought consultation with a private MD who asked him to have
a Chest Xray. However, it was not done, and he was instead
prescribed to take Ambroxol, 10 mg/tablet, 3x/day. The px
took the medication for 1 week but there was no
improvement.
V. Outcome
• Results after intervention
• Improvement? Complete? Or Partial?
VI. Recurrence
• Description
• Compare to the Initial Symptom
VII. Other Accompanying Symptoms
• Describe
VIII. Ending Statement
• What symptom/s made you decide to seek
consultation/confinement?
• E.g., because of the persistence of the difficulty of breathing
the patient decided to seek consultation
• E.g., because of the loss of consciousness, the patient was
brought to the hospital
• Important data very helpful to the diagnosis
o Can be written after ending the HPI
o Maybe a positive or a negative information
o Example: He attended a party and ate oysters and
shrimps 6 hours before the onset of Loose Bowel
Movement this implicates that the px has food
poisoning
D. INTERVAL HISTORY
• If there are previous admissions related to the HPI:
o Obtain previous records and summarize the pertinent
information as to:
Date of admission/discharge
Diagnosis, associated conditions, complications
Laboratory date
Medications given
Outcome and Disposition
• Following the summary of the previous admissions, write the
Chief Complaint
• Then, the Interval History, follows the Chief Complaint
o It will replace the HPI
o Use for chronic conditions with numerous previous
admissions for the same illness
o It details the course of the illness from the date of last
discharge to the present admission
• Example. The patient is diagnosed of Bronchial Asthma since
he was 16 years old, for which he has several attacks of 3-5x
in a year, the last of which was in Dec 2020 when the patient
was admitted sue to a severe attach for which he was
intubated and hooked to a mechanical ventilator. The patient
stayed in the ICU for 5 days after which he was extubated and
was treated for concomitant Pneumonia. Other laboratory
revealed that the patient has Anemia, his ECG was normal,
and the Spirometry revealed improvement of the Hypoxemia
with the Bronchodilator. The patient was discharged after 20
days with home medication.
o AFTER THIS YOU WILL PLACE THE CHIEF COMPLAINT
+ NO HPI
o Since the patient was discharged last Dec 2020, there
was no recurrence of dyspnea until 6 days PTA when
DOKKAEBI
 the patient developed productive cough, yellowish • Documents major or genetic disorders in the patient’s
sputum, non-blood streaked, with associated fever immediate and extended family
and developed dyspnea 3 days PTA. The dyspnea • It is helpful in determining patterns of disease within the
became severe for which the patient sought family
consultation and hence, the admission. • One way to record a family history is by drawing a family
E. PAST MEDICAL HISTORY (PMI) tree called pedigree or genogram. Include at least 2
Comprises the tertiary history that imparts additional data that generations
maybe relevant to the patient’s present medical condition • Another way to record a family history is to inquire about
1. Childhood Illness current health conditions of parents, sibling, children
• Must be specific • Heredofamilial Disease:
• Don’t’ use “usual childhood diseases” o History of significant illness such as hypertension,
o Be specific: Measles, Mumps, Chickenpox, etc. diabetes, cancer, tuberculosis or any psychiatric
• Indicate the date, S/S, complications if any illness in the family
• Secure details of all previous major childhood and adult • Death: cause, date, age at death
illnesses (whether it warranted hospitalization or not), G. PERSONAL AND SOCIAL HISTORY
surgeries, accidents and injuries • This part of the medical history provides the physician with
2. Accidents / Injuries the psychosocial factors surrounding the patient
• Indicate date, type, sequalae • This will determine the ability of the patient and his family
• Example: to accept and understand the present medical problem
o You said you have hypertension for 10 years. Can and follow the diagnostic and therapeutic plans
you tell me what is your highest blood pressure that • Educational Attainment
was taken? What is your usual blood pressure • Occupation: Previous and present
range?
• Marital status
Did you feel anything when your BP was high
o Describe present relationship
such as headache, dizziness, or nape pain?
o What age got married/or entered a relationship
Did you consult a doctor for this?
o Spouse health condition
What medications are you taking?
o Children health condition
Are you taking it regularly?
• Living Condition
o You told me you underwent a gallbladder removal 2
years ago due to gallbladder stones. o Housing: ventilation, source of water, waste
disposal, toilet
Where was the operation done?
o Economic condition
How was the stone discovered?
Was an ultrasound done • Where patient was born and raised and by whom (by
Did you feel anything that led to its discovery? parents, single parent or guardians)
Was there any complication before, during or o Living arrangements/family structure/positions in
after operation? the family out of how many siblings
3. Immunizations o How things at home?
Family background – educational
• Specify the date and type of vaccine received
backgrounds of parents, patient, siblings
• Avoid using the term “complete immunization” o Living conditions (residential/rented/owned)
• Both childhood and adult immunization Type of community
4. Surgeries o Interpersonal relationship with family and peer
• Full details including type, date, place/ hospitals, results group
and complications, Dx • Habits
5. Allergies o Diet, coffee, tea
• Specify allergens, reactions (S/S) o Eating and sleeping pattern
• Clarify o Hobbies
• Document any allergic reaction like difficulty of breathing, o Alcohol Intake: amount, type, frequency
rashes and fever Do not put “occasional”
• Record allergies that are drug and nondrug related (food, What age did alcohol intake started?
dye, seasonal, environmental) – include reactions and last o Smoking: kind, when started
estimated occurrence How much = Pack years = (# of
6. Hospitalizations or Other illness not related to HPI packs/day) (# of years smoking)
• Date o Use of prohibited drugs
• Place of Admissions o Exercise
• S/S o Food preference
o Travel to other places
• Laboratories done and results
• Sexual Practices
• Medicines given
• Environmental Exposure
• Diagnoses
o Recent travel to places that may cause a disease
• Discharge condition o Exposure to chemical or physical agents
• Home medications and instructions H. MENSTRUAL AND OB-GYNE HISTORY
• Follow-up • Menstrual History
F. FAMILY HISTORY o Menarche
• Health status of parents and siblings Age
o Age and current health status Description of 1st Menses as to: duration,
o Illness symptoms, menstrual flow
o If deceased o Subsequent Menstruation
Age at time of death Interval, duration, amount of flow, symptoms
Cause of death/symptoms Last Menstrual Period (LMP), Previous
Before he died Menstrual Period (PMP)
o Menopause: age, symptoms

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 No LMP and PMP • Head and Neck
• Obstetrical History o Eyes { } blurring of vision { }photophobia
o Gravidity and Parity { }Doubling of vision { }redness
G= #of Pregnancies { } Itchiness { }Pain { }Lacrimation
P= # of deliveries of live babies o Nose { } epistaxis (nosebleed) { }Discharge
4 Digits (T P A L) { }obstruction { } abnormal sense
• F/T = Full Term (36 wks above) { }sinus pain
• P= Premature (36 wks below) o Throat { } Sore throat { } Tonsillar pain
• A = Abortion {}Hoarseness
o Ears { } Deafness { } Tinnitus (ringing)
• L= Living
{ }discharge { } Otalgia (pain)
Example: G-6 and P-6
o Mouth { } bleeding gums { }sore
• 4 digits (5-1-0-6) { }dental pain { } Disturbance of taste
o F= 5 o Neck { }Stiffness{ }mass
o P=1 { }sensation of lump in the throat
o A=0
• Respiratory
o L=6
{ } dyspnea (shortness of breath) { } chest pain
o Describe each pregnancy as to:
{ }cough { } backpain
Manner of delivery
• Cardiovascular
• Spontaneous Vaginal
{ }chest pain { }palpitation { }dyspnea { }orthopnea
• Cesarian Section { }easy fatigue { }SOB
• Forceps Extraction • Gastro-intestinal
Place of Delivery { } Poor appetite { }dysphagia (difficult in swallowing)
Complications { }nausea { } vomiting { }diarrhea { }constipation
• Gynecological History { }abdominal pain { } Flatulence (bloated)
o Includes onset of menstruation (menarche) { } Abdominal enlargement { }Steatorrhea
o Menopause (fat in feces) { } Melena (black stool)
o Regularity, amounts (pads/days), duration of { }Hematemesis (vomits blood)
menstruation { }Hematochezia (blood in anus/stool)
o History of: • Cardiovascular
Vulvo-Vaginitis, Cervicitis, PID { } chest pain { } palpitation { }dyspnea
Gynecological Diseases: Ovarian Cyst, H. { }orthopnea (sensation of breathlessness)
Mole, Pelvic Malignancy, etc. { } easy fatigue { } SOB (shortness of breath)
Gynecological Transmitted disease • Genitourinary
o Sexually Transmitted Disease { } Dysuria (painful urination)
o Sexual History and Activity { }Flank/Suprapubic pain (lower abdomen)
o Symptoms such as: { }Frequency (how many times)
Vaginal discharge, painful sexual intercourse, { } dribbling (shaking penis)
vaginal bleeding/spotting { }Incontinence (urge to urinate)
I. FAMILY PLANNING { } hematuria (blood in the urine)
• Natural { }Oliguria (less urine) { } Polyuria (passage of stone)
o Rhythm, Withdrawal { }Discharge (mass in urine)
• Artificial • Musculoskeletal
o Condom, Diaphragm, Oral Contraceptive pills, { } muscle pain { } joint pain and stiffness { } swelling
others { }bone deformity { }weakness { }atrophy
J. REVIEW OF SYSTEMS { }hypertrophy { }restriction of motion
• The second history that expands on the primary history (HPI) • Endocrine
• It provides associated symptoms and other co-morbidities { } weight change { }temp intolerance { }Palpitation {
which may be present } Polyuria { }Polydipsia { }Polyphagia
• A rundown of questions involving all other systems not dealt { }abnormal growth { }Irritability
with HPI or interval history provide important information that • Neurologic
may be part of the general presentation of the disease that { } Syncope { }Seizures { }weakness { }Paralysis
could otherwise have been missed { }Speech disturbance { }headache { }tremors
• A comprehensive survey of all complaints referable to each { } loss of memory { } dizziness
body system { } loss of consciousness { } abnormality of
• A search for symptoms that may have escaped the taking of coordination
the present illness • Psychiatric
• Begins by asking an open-ended question followed by the { } Anxiety { } Depression { } Hallucination
appropriate list of symptoms { } Delusion { }Paranoia { }Violent behavior
• Most importantly, it may identify other problems in the patient { }Mood change { }Sleep disturbance
that you must attend to maybe sooner that together with or { }Difficulty concentrating
later than the present medical illness • Hematologic
K. MANNER OF APPROACH { } easy bruisability { } Easy fatigability { }Pallor
{ }Abnormal bleeding
• General <Constitutional Symptoms>
{ } Fever { } Chills { } Malaise { }Weight Change B. REFERENCES
{ } Change in Sleep pattern A. Lecture and Slides by Dra. Divina Fundimera, Sept
• Integumentary 13,2021
{ } Pruritus (itchy) { } Pigmentation { } Texture change B. Transes From Batch 2023 and 2024
{ }Change in hair { }Abnormal nail growth
{ }mole change { }excessive sweating

8|Clinical Medicine DOKKAEBI