[01.13] History-Taking & Physical Exam (Documentation_ Writing & Recording Medical History) V2

Concise, legible, and well-organized manner

What are the characteristics of how a patient's story from a clinical encounter should be recorded?

To apply knowledge and problem-solving skills

What is the objective related to creating a Medical Write-Up?

Identifying Information, Chief complaint, History of present illness, Temporal profile, Review of systems, Past medical history, Maternal/Birth history, Nutritional history, Immunization history, Developmental history, Family history, HEADSS for adolescents, Personal/Social history, Sexual history, Stakeholder analysis, Physical examination, Laboratory (if applicable), Problem list, Assessment/Plan

What are the basic structural components of a Medical Write-Up?

Initials, Age, Gender, Marital status, Religion (if relevant), Informant and relation to patient, Reliability of informant

What specific details should be included in the "Identifying Information" section of a medical write-up?

Believability

What aspect of a write-up can be determined by checking the reliability of the informant?

No grade

What is the grading system for checking informant reliability (e.g., 75% reliable)?

How you perceive the person when you are taking his or her history

What primarily determines the perception of informant reliability?

Consistent answers

What kind of answers from an informant suggest reliability?

"I don't know"

What common phrase from a patient or informant can cause their reliability to be questioned?

You were there to witness what happened

Under what specific condition can an informant be considered 100% reliable?

Subjective measure

Is informant reliability an objective or subjective measure?

Medical management

Religion may be important for what later aspect of patient care?

Brief statement of primary problem (including duration) that caused family to seek medical attention

What is the definition of a Chief Complaint?

Dizziness (umiikot ang paligid)

What was the chief complaint in the example of Jose Reyes?

Abdominal pain for 2 days

What was the chief complaint in the example of Juan Santos, a 40-year-old man with ulcerative colitis?

Past Medical History (PMH)

Where does a non-active or irrelevant prior diagnosis like nephrolithiasis belong, rather than the Chief Complaint?

The details of the chief complaint

What should be expanded upon in the History of Present Illness section?

Concise chronological account of the illness, with full description of symptoms (pertinent positives) and pertinent negatives

What kind of account defines the HPI?

Chronic problem

If the chief complaint is a direct extension of an ongoing chronic problem, what should the HPI begin with?

Original diagnosis (date, presenting symptoms and signs, diagnostic test), Current management and control of symptoms, Complications, Most recent objective measure of disease

What information should be included about a chronic problem at the beginning of an HPI?

Character, Location, Intermittent/constant, Progressive, stable or improving, Any prior episodes, Timing and duration, Aggravating or alleviating features, Associated symptoms

What details should be included for a well-characterized history in the HPI?

Deep or superficial, well or poorly localized and radiation

If the chief complaint is pain, what additional details should be noted in the HPI?

Treatments and their effects, Pertinent prior laboratory or radiology studies, Information obtained from a chart review, Outside records, or a referring MD

Besides symptom description, what other types of information should be included in the HPI?

IMPRESSION portion of the write-up

Where should your diagnostic impression be reserved in the medical write-up?

"Differential diagnoses"

What concept do "Pertinent Negatives" reflect?

Symptoms related to the same organ system as the chief complaint, Constitutional symptoms (e.g., fever, chills, weight change), Relevant epidemiologic data, risk factors and exposures

What specific categories of information should pertinent negatives include?

Weight change, chills, dysphagia, odynophagia, nausea, vomiting, jaundice or melena

In the example of Mr. Santos, what constitutional or related symptoms were reported as absent pertinent negatives?

Ingestion of unpasteurized dairy products, well water or raw meat/fish; exposures to antibiotics or other new medications; camping or recent travel outside the city; family members who became ill

In the example of Mr. Santos, what epidemiologic pertinent negatives were reported as absent?

Specific as possible, using the patient's own words whenever possible and quantifying whenever possible

What general tips should be followed when describing symptoms in the HPI?

Avoid burying important information in a mass of excessive detail

What should be avoided to ensure clarity and readability in the HPI?

With an explanation why the patient came to the hospital that day

How should the HPI conclude?

Paragraph form

In what specific format must the HPI be written?

All the pertinent positives and negatives that are part of the chief complaint

What should be included in the HPI regarding positives and negatives?

English translation

If a Filipino term is used in the patient's own words, what should also be included?

Visual representation of the significant symptoms of the patient

What is a Temporal Profile?

Ensure different symptoms are presented sequentially, account for changes in severity and frequency, and check for "time holes"

What is the purpose of the Temporal Profile as a check and balance mechanism?

Picture representation of the HPI

How is the Temporal Profile considered in relation to the HPI?

Gaps in the patient’s history

What can the Temporal Profile help visualize?

"Event" or "Consult"

What do the letters "E" or "C" signify in a Temporal Profile?

Severity of the symptoms

What does the Y-axis represent in a Temporal Profile?

No standard set of symbols

Is there a standard set of symbols used in a Temporal Profile, like a genogram?

Discuss all systems not already discussed in the HPI

What is the primary content of the Review of Systems?

HPI

Where do pertinent positive and negative symptoms dealing with the present illness belong, instead of the ROS?

Redundant

Why should information already included in the HPI or PMH not be repeated in the ROS?

Problem list

Why is the ROS important?

Symptoms

What specific type of information is the Review of Systems about?

Subjective

Is the Review of Systems subjective or objective?

Physical Exam

Which section is considered objective, in contrast to the subjective ROS?

Significant past medical problems

What type of problems are delineated in the PMH?

Prenatal, birth, neonatal, and feeding histories

What other items may be included in the PMH, whose importance depends on the patient's age and reason for visit?

Current medications (including over-the-counter, homeopathic, herbal, supplements)

What details should be noted for major medical illnesses?

Operations and dates

What should be listed for major surgical illnesses?

Dates and diagnoses

What should be listed for previous hospital admissions?

Latest laboratory and ancillary tests

What recent medical data should be included?

Adverse reactions to any medications or homeopathic preparations/herbal/supplement

What should be documented regarding known allergies?

Type of reaction

What specific detail about an allergic reaction should be noted?

Idiosyncratic reactions or side effects

What are many symptoms perceived as "allergies" actually, according to the source?

Hives, swelling, anaphylaxis, emesis, abdominal pain, diarrhea

What are examples of specific types of reactions that should be noted for allergies?

"Controlled", "compliant", and "not compliant"

What terms should be used to describe the status of maintenance medication for identified illnesses in the PMH?

Problem list and management

What can identified illnesses in the PMH aid in?

No

Is it necessary to list down all surgeries in the PMH?

Maternal age at delivery, gravidity/parity and history of spontaneous abortions (miscarriages)

What maternal information is included?

Bleeding, Trauma, Hypertension, Fevers, Infectious illnesses, Medications, Drugs/ illicit substances, Alcohol, Smoking, Rupturing of membranes

What aspects of maternal health during pregnancy should be noted?

Gestational age at delivery

What aspect of the pregnancy's duration is included?

Length of labor, fetal distress, type of delivery (vaginal, cesarean section), use of forceps, anesthesia, breech delivery; duration of ruptured membranes, maternal treatment with medications and their timing

What details about labor and delivery are recorded?

Birth weight, Apgar scores, breathing problems, use of oxygen, need for intensive care, hyperbilirubinemia/jaundice, birth injuries, feeding problems, length of stay in the hospital after birth

What aspects of the neonatal period are included?

Breast or bottle fed, types of formula, frequency and amount, reasons for any changes in formula

What details are included about early feeding?

When introduced, problems created by specific types of foods or any adverse reactions

What information is recorded about solids?

Fluoride use, Other nutritional supplements, Nutritional balance, Meal frequency, Fluid intake (including milk, juice, water, and sports drinks), Present diet

What other details constitute the nutritional history?

Be specific, not just "up to date"

How should immunization status be described?

Adverse reactions to any vaccine, Number of primary doses and boosters given, Adult vaccinations given

What specific details are expected in the immunization status?

Ages at which milestones in all major streams of development (gross motor, visual-motor/problem-solving, language, and social/adaptive) were achieved and current developmental abilities

What is the primary focus of developmental history?

Present grade, specific problems, interaction with peers

What school-related skills are covered?

Enuresis, temper tantrums, thumb sucking, pica, nightmares

What examples of behavior are noted?

Home and school (including current grade level), Alcohol use, Illicit drug use, Depression, Sexual activity, Suicide, Exposure to violence (including weapons)

What specific areas are covered by HEADSSS for adolescents?

Last two generations

How many generations should be included in a family tree if constructed?

Cardiac disease, hypertension, stroke, diabetes, cancer, abnormal bleeding, allergy, asthma, epilepsy, childhood diseases or adult diseases with childhood onset (mental retardation, congenital anomalies, chromosomal problems, growth problems)

What types of illnesses should be noted in the family history?

Consanguinity and ethnic background

What genetic and cultural factors should be documented?

Patient’s chief complaint

What aspect of family history should be specifically noted as related to the patient?

Occupation, level of education

What aspects of patient's professional and academic life are included?

Living situation and condition (i.e type of dwelling, source of water, waste disposal), social supports, marital status

What details about the patient's living circumstances are noted?

Composition of the family (including extended family and other people living in the house)

What should be detailed about the patient's family structure?

Smoking, Alcohol consumption, Illicit drug use

What habits are specifically mentioned?

Sexual history

What personal detail may be included here if not in HEADSSS?

Physical activity/exercise, Hobbies and interests

What other lifestyle elements are part of this history?

Tool to analyze the various positions of people involved and their level of influence in the context of a case or problem

What is Stakeholder Analysis?

To help you understand who has influence over the patient and who could support a patient’s journey towards healing

What is the main purpose of Stakeholder Analysis in the doctor-patient context?

Identify stakeholders who could influence the patient (negatively or positively), Understand how other people shape a patient’s behavior, Find levers for changing a patient’s attitude and behavior

What three specific insights can Stakeholder Analysis provide about a patient's support network?

Towards a healthier lifestyle

What kind of personal changes can be influenced using this tool?

Influencing others

Leadership, in the context of stakeholder analysis, is primarily about what, rather than position or authority?

Stakeholder/Role in healthcare, Stake/WIIFM (What's in it for me?), Stand on the intervention, Intensity of stand, Degree of influence, Insight/Action

What are the column labels in a sample Stakeholder's Analysis?

Breadwinner, caregiver, adviser, and BFF

What are examples of roles a stakeholder might play in a patient's healthcare?

Supportive, Neutral, Non-supportive

What are the possible stands on an intervention listed in the analysis?

Neutral people

Which type of people should be the focus because they could be more open to changing their position?

High, Medium, Low

What are the levels of intensity of stand and degree of influence?

Notes on how to handle the stakeholder

What is recorded under "Insight/Action" in the stakeholder analysis?

To encourage your patients to bring to the consultation their close relatives and friends

What may be required to reach out to people around the patient, based on stakeholder analysis?

Financing the patient’s medical treatment (Ex. HMO, insurance)

What financial entities are considered stakeholders?

"Why do you want to get well?" and "Who will help you get well?"

What two questions does Stakeholder Analysis help answer?

Organized system-based approach

How should the physical examination be recorded?