Data and Time of History
The date is always important. Be sure to document the time you evaluate the patient, especially in urgent, emergent, or hospital setitngs.
These include age, gender, marital status, and occupation. The source of history or referral can be the patient, a family member or friend, an officer, a consultant, or the clinical record. Identifying the source of referral helps you assess the quality of the referral information, questions you may need to address in your assessment and written response.
Document this information, if relevant. This judgment reflects the quality of the information provided by the patient and is usually made at the end of the interview. For example, “The patient is vague when describing symptoms, and the details are confusing,” or, “The patient is a reliable historian.”
Make every attempt to quote the patient’s own words. For example, “My stomach hurts and I feel awful.” If patients have no specific complaints, report their reason for the visit, such as “I have come for my regular check-up” or “I’ve been admitted for a thorough evaluation of my heart.”
This Present Illness is a complete, clear, and chronologic description of the problems promoting the patient’s visit, including the onset of the problem, the setting in which it developed, its manifestations, and any treatments to date.
- Each principal symptoms should be well characterized, and should include the seven attributes of a symptom: 1) location; 2) quality; 3) quantity or severity; 4) timing, including onset, duration, and frequency; 5) the setting in which it occurs; 6) factors that have aggravated or relieved the symptom; 7) associated manifestations. It is also important to query the “pertinent positives” and “pertinent negatives” drawn from sections of the Review of Systems that are relevant to the Chief Complaint(s). The presence or absence of these additional symptoms helps you generate the differential diagnosis, which includes the most likely and, at times, the most serious diagnoses, even if less likely, which could explain the patient’s condition.
- Other information is frequently relevant, such as risk factors for coronary artery disease in patients with chest pain, or current medications in patients with syncope.
- The Present Illness should reveal the patient’s response to his or her symptoms and what effect the illness has had on the patient’s life. Always remember, the data flow spontaneously from the patient, but the task of oral and written organization is yours.
- Patients often have more than one symptoms or concern. Each symptom merits its own paragraph and a full description.
- Medications should be noted, including name, dose, route, and frequency of use. Also, list home remedies, nonprescription drugs, vitamins, mineral or herbal supplements, oral contraceptives, and medicines borrowed from family members or friends. Ask patients to bring in all their medications so that you can see exactly what they take.
- Allergies, including specific reactions to each medication, such as rash or nausea, must be recorded, as well as allergies to foods, insects, or environmental factors.
- Note tobacco use, including the type. Cigarettes are often reported in pack-years. If someone has quit, note for how long.
- Alcohol and drug use should always be investigated and is often pertinent to the Present Illness.
- Childhood illnesses: These include measles, rubella, mumps, whooping cough, chickenpox, rheumatic fever, scarlet fever, and polio. Also included are any chronic childhood illnesses.
- Adult illnesses: Provide information relative to adult illnesses in each of the four areas: 1) medical: illnesses such as diabetes, hypertension, hepatitis, asthma, and human immunodeficiency virus; hospitalizations; number and gender of sexual partners; and risk-taking sexual practices; 2) surgical: dates, indications, and types of operations; 3) obstetric/gynecologic: obstetric history, menstrual history, methods of contraception, and sexual function; 4) psychiatric: illness and time frame, diagnoses, hospitalizations, and treatments.
Under family history, outline or diagram the age and health, or age and cause of death, of each immediate relative including parents, grandparents, siblings, children, and grandchildren. Review each of the following conditions and record whether they are present or absent in the family: hypertension, coronary artery disease, elevated cholesterol levels, stroke, diabetes, thyroid or renal disease, arthritis, tuberculosis, asthma or lung disease, headache, seizure disorder, mental illness, suicide, substance abuse, and allergies, as well as symptoms reported by the patient. Ask about any history of breast, ovarian, colon, or prostate cancer. Ask about any genetically transmitted diseases.
Personal and Social History
The personal and social history captures the patient’s personality and interests, sources of support, coping style, strengths, and concerns. It should include occupation and the last year of schooling; home situation and significant others; sources of stress, both recent and long-term; important life experiences such as military service, job history, financial situation, and retirement; leisure activities; religious affiliation and spiritual beliefs; and activities of daily living. Baseline level of function is particularly important in older or disabled patients. The personal and social history includes lifestyle habits that promote health or create risk, such as exercise and diet, including frequency of exercise, usual daily food intake, dietary supplements or restrictions, and use of coffee, tea, and other caffeinated beverages, and safety measures, including use of seat belts, bicycle helmets, sunblock, smoking detectors, and other devices related to specific hazards. Include sexual orientation and practices and any alternative health care practices. Avoid restricting the personal and social history to only tobacco, drug, and alcohol use. An expanded personal and social history personalizes your relationship with the patient and builds rapport.
Review of Systems
- General: Usual weight, recent weight change, clothing that fits more tightly or loosely than before, weakness, fatigue, or fever.
- Skin: Rashes, lumps, sores, itching, dryness, changes in color; change in hair or nails; changes in size or color of moles.
- HEENT: 1) head: headache, head injury, dizziness, lightheadedness; 2) eyes: vision, glasses or contact lenses, last examination, pain, redness, excessive tearing, double or blurred vision, spots, specks, flashing lights, glaucoma, cataracts; 3) ears: hearing, tinnitus, vertigo, earaches, infection, discharge. If hearing is decreased, use or nonuse of hearing aids; 4) nose and sinuses: frequent colds, nasal stuffiness, discharge, or itching, hay fever, nosebleeds, sinus trouble; 5) throat: condition of teeth and gums, bleeding gums, dentures, if any, and how they fit, last dental examination, sore tongue, dry mouth, frequent sore throats, hoarseness.
- Neck: “Swollen glands,” goiter, lumps, pain, or stiffness in the neck.
- Breasts: Lumps, pain, or discomfort, nipple discharge, self-examination practices.
- Respiratory: Cough, sputum (color, quantity; presence of blood or hemoptysis), shortness of breath (dyspnea), wheezing, pain with a deep breath (pleuritic pain), last chest x-ray. You may wish to include asthma, bronchitis, emphysema, pneumonia, and tuberculosis.
- Cardiovascular: “Heart trouble”; high blood pressure; rheumatic fever; heart murmurs; chest pain or discomfort; palpitations; shortness of breath; need to use pillows at night to ease breathing (orthopnea); need to sit up at night to ease breathing (paroxysmal nocturnal dyspnea); swelling in the hands, ankles, or feet (edema); results of past electrocardiograms or other cardiovascular tests.
- Gastrointestinal: Trouble swallowing, heartburn, appetite, nausea. Bowel movements, stool color and size, change in bowel habits, pain with defecation, rectal bleeding or black or tarry stools, hemorrhoids, constipation, diarrhea. Abdominal pain, food intolerance, excessive belching or passing of gas. Jaundice, liver, or gallbladder trouble; hepatitis.
- Peripheral vascular: Intermittent leg pain with exertion (claudication); leg cramps; varicose veins; past clots in the veins; swelling in calves, legs, or feet; color change in fingertips or toes during cold weather; swelling with redness or tenderness.
- Urinary: Frequency of urination, polyuria, nocturia, urgency, burning or pain during urination, blood in the urine (hematuria), urinary infections, kidney or flank pain, kidney stones, ureteral colic, suprapubic pain, incontinence; in males, reduced caliber or force of the urinary stream, hesitancy, dribbling.
- Genital: Male: Hernias, discharge from or sores on the penis, testicular pain or masses, scrotal pain or swelling, history of sexually transmitted infections and their treatments. Sexual habits, interest, function, satisfaction, birth control methods, condom use, and problems. Concerns about HIV infection. Female: Age at menarche, regularity, frequency, and duration of periods, amount of bleeding; bleeding between periods or after intercourse, last menstrual period, dysmenorrhea, premenstrual tension. Age at menopause, menopausal symp- toms, postmenopausal bleeding. If the patient was born before 1971, exposure to diethylstilbestrol (DES) from maternal use during pregnancy (linked to cervical carcinoma). Vaginal discharge, itching, sores, lumps, sexually transmitted infec- tions and treatments. Number of pregnancies, number and type of deliveries, number of abortions (spontaneous and induced), complications of pregnancy, birth-control methods. Sexual preference, interest, function, satisfaction, any problems, including dyspareunia. Concerns about HIV infection.
- Musculoskeletal: Muscle or joint pain, stiffness, arthritis, gout, backache. If present, describe location of affected joints or muscles, any swelling, redness, pain, tenderness, stiffness, weakness, or limitation of motion or activity; include timing of symptoms (e.g., morning or evening), duration, and any history of trauma. Neck or low back pain. Joint pain with systemic symptoms such as fever, chills, rash, anorexia, weight loss, or weakness.
- Psychiatric: Nervousness, tension, mood, including depression, memory change, suicidal ideation, suicide plans or attempts. Past counseling, psycho- therapy, or psychiatric admissions.
- Neurologic: Changes in mood, attention, or speech; changes in orientation, memory, insight, or judgment; headache, dizziness, vertigo, fainting, black- outs; weakness, paralysis, numbness or loss of sensation, tingling or “pins and needles,” tremors or other involuntary movements, seizures.
- Hematologic: Anemia, easy bruising or bleeding, past transfusions, transfusion reactions.
- Endocrine: “Thyroid trouble,” heat or cold intolerance, excessive sweating, excessive thirst or hunger, polyuria, change in glove or shoe size.
- Abdominal pain
- Acid-base abnormalities
- AIDS/HIV infection
- Back pain
- Bleeding disorders
- Chest pain
- Cough, fever, and respiratory infections
- Delirium and dementia
- Diarrhea, acute
- GI bleeding
- Hyponatremia and hypernatremia
- Jaundice and abnormal liver enzymes
- Joint pain
- Kidney injury, acute
- Sore throat
- Weight loss, unintentional
- Wheezing and stridor