Protect Patient Confidentiality:
DO NOT include any Protected Health Information (PHI) in your real patient write-ups.
You may report their age but not date of birth, and do not include their first or last name.
It may be easiest to make up a fictitious name and include it in quotes in the Pt ID section at the very beginning of the write-up. Then, use that fictitious name throughout your write-up. The name in quotes at the beginning tells us that you are consciously using a fictitious name, appropriately.
APM FMS 501–503 Guide to the Medical History
Recommended Reading
Bates’ Guide to Physical Examination and History Taking, 12th edition, Chapter 1.
Principles of the Interview
Most diagnoses are made on the basis of a history, the physical examination, and any further investigations are often confirmatory. Fully describe the dimensions of each symptom: time, quantity, location, aggravating factors, relieving factors, quality, setting, and associated symptoms.
The experienced clinician formulates and tests hypotheses while conducting the interview and gathering the history. Ask: “What is the worst thing this could be?” Then ask, “What else could this be?”
- Identifying Data
- Source/Reliability
- Chief Complaint(s)
- Present Illness
- Medications
- Allergies
- Past History
- Childhood Illnesses
- Adult Illnesses
- Health Maintenance
- Family History
- Personal and Social History
- Review of Systems
Tips for Successful Interviewing
- A helpful question for illnesses when the onset is difficult for the patient to define: “When was the last time you can remember feeling perfectly well?”
- Facts are statements that are true; information consists of facts presented in a useful manner.
- Avoid writing down a whole list of “true” statements when you document your patient’s history. Think about presenting your data in a useful and logical manner.
- An effective approach in one patient may need to be modified for the next—good communication skills are vital to effective information-gathering.
- The interview is flexible, the written record is rigid. Organize your thoughts as you go, or soon after the interview is over.
- Have a structure in mind to compose the history of present illness, for example:
Mr./Ms./Mrs./Miss ___________(name) is a __________ year old __________ (gender, details), who is in clinic today with a chief complaint of __________ (symptoms in own words) of __________ duration. The history of the present illness begins __________ ago when s/he first noted the (gradual/sudden/other) onset of __________.
In initial sessions, we will focus less on the starred items, which warrant their own in-depth exploration.
General: Fevers, chills, night sweats, weight loss or weight gain (clothes fit looser or more tightly), weakness
Dermatologic: Rashes or moles/changes in size or color of moles, changes in hair or nails
HEENT:
- Head: Headaches, head injury, dizziness, or lightheadedness
- Eyes: Changes in vision including double vision, eye pain, photophobia
- Ears: Hearing loss, tinnitus, vertigo, otitis
- Nose: Epistaxis, nasal stuffiness, sinus trouble, hay fever
- Throat (oropharynx): Bleeding gums, frequent sore throats, oral ulcers, or hoarseness
Neck: “Swollen glands,” lumps, pain, or stiffness of the neck
Breasts: Lumps, pain, discharge
Respiratory: Cough, shortness of breath or wheezing, chronic sputum production, hemoptysis.
Cardiovascular: Chest pain, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, pedal edema, palpitations, or claudication.
GI: Nausea, vomiting, abdominal pain, dysphagia, diarrhea, constipation or any change in bowel habits, hepatitis, jaundice, hematemesis, melena, hematochezia
GU: Dysuria, frequency, urgency, hesitancy or hematuria, [men: penile discharge; women: pelvic infections, vaginal discharge, bleeding]
MSK: Pain, swelling, redness, stiffness, or locking of joints
Psych: Depression, anxiety, sleep disturbance, or hallucinations
Neuro: Loss of consciousness, seizures, paralysis, weakness, numbness, or involuntary movements
Hematopoietic: Prolonged bleeding, easy bruising, or known anemia.
Endocrine: Polyuria, polydipsia, heat or cold intolerance