THE MEDICAL HISTORY Dr Haidar F Al Rubaye

THE MEDICAL HISTORY Dr Haidar F. Al -Rubay’e

HISTORY TAKING The history is a patient’s account of their illness together with other relevant information that you have gleaned (collected) from them. Like all things in medicine, there is a tried and tested sequence which you should stick to and is used by all practitioners It is good practice to make notes while talking to the patient that you can use to write a thorough history afterwards. § Do not write every word they say as this breaks your interaction? By the end of history taking you should have a good idea as to a diagnosis or have several differential diagnosis in mind. The examination and the investigations are you chance to confirm or refute these by gaining more information.

THE STANDARD HISTORY FRAMEWORK You should break the history down under the following headings and record it in the notes in this order: Personal information Presenting (Chief) Complaint History of Presenting Illness Systematic enquiry (Review of Systems) Past medical history & Past Surgical History Drug history Family history Social history

PERSONAL INFORMATION Name Age Gender Address Occupation Marital status Religion!!? Date of admission Date of examination In certain casessource of information

THE PRESENTING (CHIEF) COMPLAINT This is the patient’s chief symptom(s) in their own words and should no more than single sentence § Another definition: The main symptom(s) that make the patient seeks medical help. § Another definition: The main symptom(s) that bring the patient to the hospital. Features that are required in the chief complaint § It is preferable to be one symptom but it is possible to have patient with multiple symptoms and he thinks that all of them are important and are his cause of seeking medical help, if this happen, they must written in one sentence. § It must be written using the patient’s own terms or words § It is not allowed to use medical terms (this feature is applied only for the chief complaint, in the next parts of the history, you can use medical terms) § It must include the duration of the chief complaint

It is important to mention that the chief complaint must be written correctly because it is essential to create the list of differential diagnosis. Ask the patient an open ended question like: § What’s the problem? § What made you come to the doctor You should choose a phrase that suits you and your manner.

HISTORY OF THE PRESENT ILLNESS Here, you ask about and document the details of the chief complaint and all of the symptoms that are observed in the patient’s current illness So, history of the present illness must include the analysis of each symptom mentioned by the patient and related to his current illness By the end of this you should have a clear idea about the nature of the problem along with how and when it started, how the problem has progressed over time, and what impact it has had on the patient in terms of their general physical health, psychology, social and working lives.

THE HISTORY OF THE PRESENT ILLNESS IS BEST TACKLED IN 2 PHASES: 1 st phase Ask an open question and allow the patient to talk through what has happened for about 2 minutes Don’t interrupt, encourage the patient with non verbal responses and make discreet notes 2 nd Phase You should revisit the whole story asking more detailed questions This should feel like a conversation, not an interrogation This is your chance to verify time lines and the relationship of one symptom to another, clarify pseudomedical terms.

FOR EACH SYMPTOM DETERMINE: The exact nature of the symptom The onset: § The date it began § How it began (e. g. suddenly, gradually-over how long) § If long standing, why the patient seeking help now). Periodicity & frequency: § Is the symptom constant or intermittent § How long does it last each time § What is the exact manner in which it comes and goes. Severity Change over time: § Is it improving or deteriorating Precipitating factors § is there any factor that initiate the symptom Aggravating factors: § What make the symptom worse Relieving factor: § What make the symptom better Associated symptoms

FOR PAIN DETERMINE Site § Where is the pain worst Radiation § Does the pain moves anywhere else Character § i. e. dull, aching, stabbing, burning, etc. Severity Mode & rate of onset Duration Frequency Precipitating factors Aggravating factors Relieving factors Associated symptoms (e. g. nausea, vomiting, dysphagia…etc. )

By the end of the history of the present illness, you should have established a problem list. You should run through these with the patient, summarizing what you have been told and ask them if you have the information correct and if there anything further that they would like to share with you.

SYSTEMATIC ENQUIRY (REVIEW OF SYSTEMS) After talking about the present illness, you should perform a brief screen on the other bodily systems. It is important to find symptoms that the patient had forgotten about, or identifying secondary unrelated problems that can be addressed.

GENERAL SYMPTOMS Weight change (loss or gain) Change in appetite (loss or gain) Lethargy Malaise Fever

RESPIRATORY SYMPTOMS Cough Sputum Hemoptysis SOB Wheeze Chest pain

CARDIOVASCULAR SYMPTOMS SOB on exertion Paroxysmal nocturnal dyspnea Chest pain palpitations Ankle/leg swelling Orthopnea Claudication

GIT SYMPTOMS Indigestion Abdominal pain Nausea Vomiting Constipation Diarrhea Per rectal blood loss Dysphagia

GENITOURINARY SYMPTOMS Urinary frequency Hematuria Polyuria Dysuria Nocturia Menstrual problems Impotence

NEUROLOGICAL SYMPTOMS Headaches Dizziness Tingling Weakness Tremor Fits Faints, syncope Sphincter disturbance

LOCOMOTOR SYMPTOMS Aches Pain Stiffness Swelling

SKIN SYMPTOMS Lumps Ulcers Rashes Itch

PAST MEDICAL HISTORY Some aspects of the patient’s past illnesses or diagnoses may have already been covered. (in the beginning of the history of present illness). Here, you should obtain detailed information about past illness and surgical procedures. History of previous admission to hospital must be mentioned For each medical condition, determine: § When was it diagnosed? § How has it been treated?

PAST MEDICAL HISTORY-ASK SPECIFICALLY ABOUT Diabetes Hypercholestrolemia Hypertension Angina Myocardial infarction Stroke or TIA Asthma TB Epilepsy Anesthetic problems Blood transfusions

Drug history Allergies

SYMPTOMS OF HEART DISEASE Chest pain Dyspnea Palpitations Syncope Fatigue Peripheral oedema.

NEW YORK HEART ASSOCIATION (NYHA) FUNCTIONAL CLASSIFICATION Class I • No limitation during ordinary activity Class II • Slight limitation during ordinary activity Class III • Marked limitation of normal activities without symptoms at rest Class IV • Unable to undertake physical activity without symptoms; symptoms may be present at rest

CHEST PAIN Chest pain is a common presentation of cardiac disease but can also be a manifestation of anxiety or disease of the lungs or musculoskeletal or gastrointestinal systems. Differentiating points Site Radiation. Character. Provocation Onset Associated features

PAIN-STANDARD QUESTIONING Site Onset Character Radiation Associated symptoms Timing (duration, course, pattern) Exacerbating and relieving factors Severity

CAUSES OF CHEST PAIN Central • Cardiac • Ischaemic heart disease (infarction or angina) • Pericarditis/myocarditis • Mitral valve prolapse • Aortic aneurysm/dissection • Non-cardiac • Pulmonary embolism • Oesophageal disease • Mediastinitis • Costochondritis (Tietze's disease) • Trauma (soft tissue, rib) Peripheral • Pulmonary • Infarction • Pneumonia • Pneumothorax • Lung cancer • Mesothelioma • Non-pulmonary • Herpes zoster • Trauma (ribs/muscular)

Site & radiation of ischemic chest pain

SPECIFIC FEATURES OF CHEST PAIN Angina • Retrosternal dull ache or discomfort • Ill localized • Crushing, heaviness, like a tight band • Worse with physical or emotional exertion, cold weather and after eating • Relieved by rest and nitrates • Not affected by respiration or movement • Sometimes associated with SOB

Myocardial Infarction • The pain is similar to that of angina but it is: • More severe • More persistent • Associated with nausea, vomiting & sweating • Associated with Feeling of impending death

Pericarditis • Constant retrosternal • Worse on inspiration (pleuritic) • Relieved slightly by sitting forward • Not related to physical or emotional exertion

AORTIC DISSECTION Site • Often first felt between shoulder blades and/or behind the sternum Onset • Usually sudden Nature • Very severe pain, often described as 'tearing' Relieved • By nothing, tends to persist; patients often restless with pain Accompanied • By pallor, sweating, hypertension, asymmetric pulses, unexpected bradycardia, early diastolic murmur, syncope, focal neurological symptoms and signs

Esophageal spasm • Often mistake for MI or angina • A severe retrosternal burning chest pain • Onset often after eating or drinking • May be associated with dysphagia • May have history of dyspepsia • May be relieved by GTN (needs more time than that required for angina ---20 min Vs 23 min.

Esophagitis • Retresternal burning pain (heart burn) • Relieved by antacids • Onset after eating

Pleuritic (respiratory pain) • Sharp pain, worse on inspiration & coughing • Not central, may be localized to one side of the chest • No radiation • No relief with GTN • Associated with breathlessness, cyanosis e. g. respiratory symptoms or signs.

• Localized to particular spot on the chest • Worsened by movement Musculoskeletal and respiration • Tender to palpation pain

BREATHLESSNESS, SHORTNESS OF BREATH, DYSPNEA Breathlessness (dyspnoea) is an awareness of increased drive to breathe and is normal on exercise. It is pathological if it occurs at a significantly lower threshold than expected. Breathlessness is a non-specific symptom and may be caused by cardiac, respiratory, neuromuscular and metabolic conditions, or by toxins or anxiety.

ORTHOPNEA Orthopnoea is dyspnoea on lying flat and is a sign of advanced heart failure. § Lying flat increases venous return to the heart and in patients with a failing left ventricle may precipitate pulmonary venous congestion and pulmonary oedema. § The severity can be graded by the number of pillows the patient uses before feeling comfortable ('three-pillow orthopnoea'). Paroxysmal nocturnal dyspnoea is sudden breathlessness which wakes the patient from sleep choking or gasping for air § It has a similar mechanism to orthopnoea and is caused by the gradual accumulation of alveolar fluid during sleep. § Patients may sit on the edge of the bed and open windows in an attempt to relieve their distress.

CAUSES OF DYSPNEA Left ventricular failure (pulmonary congestion) Pulmonary embolism Dyspnea Any respiratory disease Anxiety

PALPITATION Palpitation is an unexpected awareness of the heart beating in the chest. Patients experience a rapid, forceful or irregular cardiac impulse and describe this as thumping, pounding, fluttering, jumping, racing or skipping. Ask them to tap out the pattern with their fingers to clarify its rate and rhythm. Palpitation may occur in sinus rhythm with anxiety, with intermittent irregularities of the heartbeat, e. g. extrasystoles, or with an abnormal rhythm (arrhythmia). Most patients do not have a sustained arrhythmia and not all patients with arrhythmia experience palpitation; for example, atrial fibrillation commonly causes an irregular heartbeat in the elderly but rarely causes palpitation. The history helps distinguish different types of palpitation. Ask about: § § onset and termination (abrupt or gradual) precipitating factors (exercise, alcohol, caffeine, recreational or other drugs) frequency and duration of episodes character of the rhythm (ask the patient to tap it out).

DESCRIPTIONS OF ARRHYTHMIAS Ventricular or atrial extrasystoles Atrial fibrillation Supraventricular tachycardia Ventricular tachycardia • 'Heart misses a beat' • Heart 'jumps' or 'flutters' • Heart 'jumping about' or 'racing' • Associated breathlessness May be unnoticed • Heart racing or fluttering • Associated polyuria • Heart racing or fluttering • Associated breathlessness • May present as syncope rather than as palpitation

SYNCOPE The term 'syncope' refers to sudden & Transient loss of consciousness due to reduced cerebral perfusion. 'Presyncope' refers to lightheadedness where the individual thinks he or she may black out. There are several mechanisms that underlie recurrent presyncope or syncope: § cardiac syncope due to mechanical cardiac dysfunction or arrhythmia § neurocardiogenic syncope in which an abnormal autonomic reflex causes bradycardia and/or hypotension. § Blackouts can also be caused by non-cardiac pathology such as epilepsy, cerebrovascular ischaemia or hypoglycaemia Cardiovascular disorders produce dizziness and syncope by transient hypotension, resulting in abrupt cerebral hypoperfusion. Recovery is usually rapid, unlike with other common causes of syncope (e. g. stroke, epilepsy, overdose).

POSTURAL HYPOTENSION Syncope on standing upright reflects inadequate baroreceptormediated vasoconstriction. It is common in the elderly. Abrupt reductions in blood pressure and cerebral perfusion cause the patient to fall to the ground, whereupon the condition corrects itself.

VASOVAGAL SYNCOPE This is caused by autonomic overactivity, usually provoked by emotional or painful stimuli, less commonly by coughing or micturition. Only rarely are syncopal attacks so frequent as to be significantly disabling ('malignant' vasovagal syndrome). Vasodilatation and inappropriate slowing of the pulse combine to reduce blood pressure and cerebral perfusion. Recovery is rapid if the patient lies down.

CAROTID SINUS SYNCOPE Exaggerated vagal discharge following external stimulation of the carotid sinus (e. g. from shaving, or a tight shirt collar) causes reflex vasodilatation and slowing of the pulse. These may combine to reduce blood pressure and cerebral perfusion in some elderly patients, causing loss of consciousness.

VALVULAR OBSTRUCTION Fixed valvular obstruction in aortic stenosis may prevent a normal rise in cardiac output during exertion, such that the physiological vasodilatation that occurs in exercising muscle produces an abrupt reduction in blood pressure and cerebral perfusion, resulting in syncope.

STOKES-ADAMS ATTACKS These are caused by self-limiting episodes of asystole or rapid tachyarrhythmias (including ventricular fibrillation). The loss of cardiac output causes syncope and striking pallor. Following restoration of normal rhythm recovery is rapid and associated with flushing of the skin as flow through the dilated cutaneous bed is re-established.

FATIGUE Fatigue may be a symptom of inadequate systemic perfusion in heart failure. It is due to: § poor sleep § a direct side-effect of medication, particularly betablockers, § electrolyte imbalance due to diuretic therapy § as a systemic manifestation of infection such as endocarditis.