University of the East

Ramon Magsaysay Memorial Medical Center, Inc.

# 64 Barangay Dofla Imelda, Aurora Boulevard Quezon City I 1 13

DEPARTMENT OF MEDICINE
Tel: 715-08-05, 715-08-6 I Loc. 262

RECORDING THE MEDICAL HISTORY

Format of the History Report (in the order of recording):
1. Patient Profile
2. Source and Reliability
3. ChiefComplaint
4. History of the Present Illness
5. Past Health Maintenance History
6. Family History
7. Review of System

PATIENT PBQEIL.E
Purpose:
1. To dtscover what shmuli in the patient's environment may be contributing to his illness.
2. To determine factors that may significantly influence diagnostic or therapeutic program for the
patient (ex. Financial resources).
3. To discover some information that may give important clue as to the cause of the patient's
ilhess.

up and his reaction to his environment and his illness.

Information to be included in the patient profile:

1. Life History
a. Name h. Education
b. Sex i. Socioeconomic status of the family
Age and birth date j Family composition and hislher place in the family
d. Place of residence k. Living environment - community, neighborhood,
e. Birthplace/ place of origin basic facilities, source of water, way of garbage disposal
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f. Race 1. Hobbies irnd interests
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b' Religion

2. Marital Status
- History,compatibility, adjustment

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 3. Occupation and Employment History
a. Nature of present and previous work
b. Presence of occupational hazards
c. Adjushnent to working situations
4. Financial Status

5. Personality type and reaction to environment

- High Strung, chronic worrier, easy going, etc.

6. Habits and Description of average day

a. Dietary and eating habits d, Use of tobacco (expressed in number of pack years)
b. Sleeping habits e. Alcohol intake
c. Exercise f. Caffeine and drug intake (substance abuse)
7. Current medications, if any
- Dose, frequency and duration of intake

souRCE ANp RELIAEU.Uy

to patient) and gauge its reliability (via percentage or good/fairlpoor)

CHIEF COMPLAINT

Guidelines in recording the Chief Complaint:

1. It is limited to a brief statement.
2. It is restricted to a single symptom or two at most.
3. It uses the patient's own words as nearly as possible.
4. It refers to a concrete complaint (symptom).
(Not vague phrases such as kidney trouble or heat trouble)
5. It includes the duration of symptom.
6. It avoids the use of diagnostic terms or diseases.

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 HIS OF THE PRESENT ILLNESS

4 BASIC COMPOI{ENTS:
A. Restatement of the chief complaint with elaboration in greater detail.
B. A history of the present problem from the time of onset.
C. A full description of the current status of the patient.
D. A summary of all significant positive and negative information"
'D Note: It is preferable to use a separate paragraph
for each chronological period and in that
paragraph analyze all symptoms completely and note positive and negative infomtation closely
related to the symptoms describe. All other significant positives and negatives should be
summarized separately in the last paragraph (4th component of the HPI).

> Doy t{' rtdmission ar consultation should be the reference date (peiod) of the onset and
progression or appeararce of other symptoms. It could be several minutes, few hours/several
hours, days weeks, months, or years prior to consultation or admission day.

TECHNIQUE OT HISTORY TAKING OT THE PRESENT ILLNESS:

(essentially a four-phase activity)
Phase l.
Obtain an account of the symptoms as the patient experiences them without introducing any bias
with direct questions. The patient should be encouraged to talk freely about his complaints with the use
ofopen ended neutral questions. These questions should help the patient recall the date his problem first
appeared.
Ex. Can you tell me when and how your problem stafted?
Tell me about your problem
What other symptoms did you notice since you became ill?
Phase 2.
This phase should provide for a detailed analysis of the symptoms described by the patient
through direct and detailed analysis of the symptom in its chronologic order and nalyze it (refer to the
topic on outline of symptom analysis).
Phase 3.
This phase should test the diagnostic possibilities suggested by the data elicited during the first
two phases. The interviewer specifically inquires about other symptoms or events that normally form
part of the usual history of the suspected problem/s.
Phase 4.
The technique in the first three phases may fail to reveal all symptoms of importance to the
present problem, especially if they are remote in time and apparently not related to the present problem.
Some symptoms may be elicited only during the review of systems. Therefore the fourth phase should
provide for analysis of symptoms that were first revealed during the review of systems.
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 Excerpt from the Sample Patient Record:
i The patient is admitted with complains of episodic vomiting of bright red blood during
the last 3 hours, associated with mid-epigastric pain.

2. Three years prior to admission, the patient first noticed gradual onset of abdominal pain
precipitated by hunger and stress in his job. (onset)

The pain had a burning quality and was located in the mid-epigastric area with no
radiation. It was initially mild, not interfering with work, but becoming moderate and sometimes
waking him up from sleep. The pain was felt when hungry but was also aggravated occasionally
after eating. Spicy food made it worse, but there were no other food intolerances. (characteristic)

Although initially there were no associated symptoms like nausea nor hematemesis, there
was an episode of passing out of black-tarry stools with weakness six months prior to admission.
An upper GI radiography showed an ulcer. At this time, pain was described as more intense, but
relieved by antacids and food intake. This recurred again a week prior to admission, with
increasing fiequency and intensity and with only slight relief from antacids. (course since onset)

3. Three hours prior to admission, still with epigastric pain, he suddenly vomited bright-red
blood three times estimated to be W to one cup full each episode at intervals of 30 minutes to an
hour with the last episode 15 minutes before arriving at the ER. He denies melena at this time but
he feels weak and a little giddy on standing up.

4. He denies history of liver disease, jaundice, or symptoms of a bleeding tendency. He

denies alcohol or aspirin ingestion. He occasionally smoked cigarettes. He has been under a lot
of stress at work lately. He denies any history of weakness or easy fatigue or shortness of breath
with exertion before the vomiting episode. He denies weight loss.

o Section I is an elaboration of the chief complaint that supplies greater detail

o Section 2 deals with the history of the present illness from the time of onset with detailed
description of the symptoms. Note that separate paragraphs deal with the symptom
onset, characteristics of the symptoms, and course since onset, as described below.
o Section 3 is a full description of the current status of the problem.
o Section 4 is a summary of all significant positive and negative information.

SYMPTOM ANALYSIS
It is ilnportant to use a standard method of analyzing a symptom. One basic outline for analyzing
symptoms:
1. Onset
a. Date of onset
I b. Manner of onset (gradual or sudden)
c. Precipitating and predispoising factors related to onset
2. Characteristic (CLITAA)
a. Character (quantity, quality, consistency, appearance)
b. Location and radiation (pain, cardiac murmur)

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 c. Intensity or severity (ie 5/10, severe)
d. Timing (continuous or intermittent, duration of each, temporal relationship to other
events)
e. Aggravating and relieving factors
f. Associated symptoms
3. Course since onset
a. Incidence
i. Single acute attack
ii. Recurrent acute attack
iii. Daily occurrences
b. Effect of therapy
c. Progress

THE SIX POINT CHECK LIST FOR HPI (by Benjamin policarpio, MD)
The HPI if elicited thoroughly and accurately will have a predictive diagnostic value of 85% or
even more. How may one be confident that he has adequately accomplished the HPI?
This is done by going through the checklist of six items: l. Components, 2. Sequence, 3.
Temporal relationships, 4. Analysis of Symptoms, 5. "Time holes", and 6. ROS, by asking yourself...

1. Do I have all the components? (signs and symptoms)

2. Do I have the correct sequence? (the sequence of components has a telling influence on the
diagnosis)
3. Do I have the correct temporal relationships between the problems and SiS? This means not only
sequence but how the signs and symptoms overlap each other within the time frame of present
illness. This is valuable in the finer point of differential diagnosis since a combination of two or
more symptoms of an illness (syndrome) will have many diagnostic possibilities.
4. Have I done an analysis of symptoms of all the components?
5. Are there "time holes" in my HPI; meaning, are there segments of time in the course of illness which
I am not clear about the behavior of a component (gone, better, worse). All components must be
accounted for within the time line of the illness.
6- Have I done a thorough review of systems? This is to cover the other components of the IIpI not
elicited in the interview, or other significant but unrelated problems that have to be looked into and
addressed therapeutically.

It is very obvious that all the imaginable problems related to the thoroughness, accuracy, and
dependability of the HPI are covered by these.

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 PAST HEALTH MAINTENANCE HISTORY

F Allergies

) Immunizations

P Pregnancies and deliveries, any abnormality

FAMILY HISTORY
D Present status of parents and siblings - Ege, health status of each, cause of death, and age at death, if
any

disease, allergies, cerebrovascular disease, mental illness

REVIEW OF SYSTEMS

overlooked in the HPI

Sample of Review of System Record

REVIEW OF SYSTEMS: (Write N if frndings are negative/normal. Place a check if findings are
positive/abnormal then describe in space provided)
Begin with a general question eg "Do you have any trouble with your eyes?", then ask specific questions
like "Has your vision changed?, etc"

GENERAL DESCRIPTION
Fever_Fatigue_Sweating Weightloss_Weakness_
SKIN
Color_Texture_Itching Rashes_Changes inhair/nails
EYES
I Visual hnpairment_Redness_Tearing Pain_
Double vision_Discharge_Trauma_
EARS
Hearing loss_Otalgia_Discharge_Tinnitus_

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 PAST HEALTH MAINTENANCE HISTORY

F Major illnesses

FAMILY HISTORY
F Present status ofparents and siblings - age, health status ofeach, cause ofdeath, and age at death, if
any

disease, allergies, cerebrovascular disease, mental illness

REVTEW Or SYSTEMS

overlooked in the HPI

Sample of Review of System Record

REVIEW OF' SYSTEMS: (Write N if findings are negative/normal. Place a check if findings are
positive/abnormal then describe in space provided)
Begin with a general question eg "Do you have any trouble with your eyes?", then ask specific questions
like "Has your vision changed?, etc"

GENERAL DESCRIPTION
Fever_Fatigue_Sweating Weight loss_Weakness
SKIN
Color_Texture_Itching Rashes_Changes inhair/nails
EYES
I Visuallmpairment_Redness_Tearing Pain_
Double vision_Discharge_Trauma
EARS
Hearing loss_Otalgia_Discharge Tinnitus

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 NOSE, THROAT, MOUTH
Nasal obstruction_Discharge_Abnormal olfactionlAnosmia_
Epsitaxis_Frequent coldslcough_Dysphagia Odynophagia_
Change in voice_Neck mass_Toothache
Dental caries_Gum bleeding Ulceration-Congenital deformities
RESPIRATORY
Cough/sputum_Difficulty of breathing_Wheezing (asthma)_
PTB exposure_Hemoptysis_
CARDIOVASCULAR
Palpitation Syncope-_Chest pain_Edema Hypertension
Orthopnea Dyspnea

GASTROINTESTINAL
Dysphagia Nausea_Vomiting Appetite_Abdominal pain_
Melena Jaundice_Bleeding_Indigestion_Heartburn_
Hematemesis_Fatty food intolerance_Stool frequency/character
Hemorrhoids Abdominal distention Hernia
URINARY
Pain_Volume_Retention_Bleeding Stream_Polyuria
Nocturia Stones Infection_Hesitancy_Urgency_Change in
color_Frequency_Dribb ling
GENITOREPRODUCTIVE
Male: Discharge_Pain Libido_sexual difficulties_
Female: Menarche_LMP_PMP_Menses : regular_duration_Amt__
Abnormalvaginalbleeding Discharge_Dysmenorrhea/pelvicpain_
Post-coital bleeding_Contraceptive use No. ofpregnancies_
Complications_Live births_Heaviest baby_lbs._PlD_
Menopause age_Postmenopausal bleeding
BREAST
Nipples_L ump_Pain_Discharge_
EXTREMITIES
Cyanosis_Clubbing_Edema Varicosity_Ulcers_Claudication
HEMATOPOIETIC SYSTEM
Excessive bleedingibruising Anemia Pica
NERVOUS SYSTEM
Headache_Tremor_Fainting spells_Seizures Dizzines/vertigo_
Head trauma Sensory perversions
MUSCULOSKELETAL
Jointstiffness_Pain_Swelling Muscleweakness_
ENDOCRINE SYSTEM
Heat/cold intolerance_Thyroid problems_Neck surgery/irradiation_
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DM indicators
PSYCHIATRIC
Moodswings_Behavioral changes Anxiety_Depression

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 TEMPORAL PROFILE DIAGRAM

occur within the time frame or course of the present illness and to what extent they overlap each
other during the period
The height ofthe symptom curve from the baseline will reflect the severity ofthe same.
Max The shape, slope ofthe synptom curve will also depict the behavior ofa symptom or
sign over the cause ofthe illness, from the onset to consult or admission.

The legend will be representing 2 or no more than 3 major symptoms of the illness, with
appropriate lines or colors, on the left side, belorv the diagram.

INTENSITY OT' The "clinical horizon" (CH) and the time lines coincide (are one and the same) with each
SYMPTOMS other. A symptom r:urve that rises above it signifies its appearance or presence. Onoe it
touches the CH or time tine, it depicts its absence or relief or disappearance at that
particular point in time.

0 onset Admission

TIMEFRAME
(hourg days, weeks, months, as the case moy be)

Legend:
Symptom A
Symptom B
Symptom C

Guidelines:
1. As much as possible it is best to have the minimum nr.rmber of symptom line (one or two or at
most thee) to represent the temporal profile of several symptoms.
A temporal profile diagram of the HPI which is cluttered defeats its very purpose ie to show at a
glance the relationship of all the components during the course of the illness.
2- Should several symptoms have similar temporal profile, use only one qrynptom line to represent
all of them.
3. The graphic symptom line can be color coded or represented by symbols such as -'- -, !
or *****
4. Should there be more than one problem or illness in the HPI, each problem/illness should be
represented by its own separate corresponding schematic diagram/temporal profile.

severity, acuteness, and tempo ovsr the time frame where it occurs. Some examples:

I Gradual onset. Progressively worsening,

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 Acute onset. Unrelenting course up to admission.

Intermittent (alternately occurring and ceasing)

Continuous. Remittent.

inv Acute episodes. Remittent + periodic

( Recurrent (total episode repeats itself at various intervals of time-hours or days.

Eg aftemoon fever every 2 or 3 days.
)

Periodic - Episode occurs in cluster of time in periods of days or weeks or months

with symptom-free period longer than the symptomatic period.

Gradual onset. Continuous. Waxing and waning.

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 days. Any symptom curve touching the baseline oO' or "clinical horizon" will be interpreted as
absent. Note that the symptom lines are curves, NOT sharp angles.
Max
.1,++
INTENSITY OF
S1TIPTOMS

\ \ \
0 6 5 4 3 2 I A
TIME LINE OR CLTNICAL HORIZON
(i.e days or hours PTA)

Legend

Jaundice
RUQ Pain
Fever

Paracetamol
Y Admission

In this example, one will see that the sequence of the components is: RUQ pain followed by jaundice
and lastly by fever. The temporal profile also clearly shows how the signs and symptoms overlap each
other. There are many conditions characterized by these 3 components, but the underlying cause or
diagnosis changes with the change in the sequence of these components. More importantly, the temporal
relationships of the three components may fumish further information as to its specific diagnosis/cause,
when there are two or more possibilities, or with the same components and sequence. The steepness and
shape of the curyes show that the RUQ pain occurred on and off to progressively worsen to 2 days PTA
until admission. Jaundice is noted four days PTA, and progressively worsens or deepens on the day of
admission. Fever was noted 2 days PTA lasting until admission. In the account of the HPI, further
description or elaboration can be given to the RUQ pain as colicky and severe, while fever may be
described as remittent, septic with swings between 38 to 40C or continuous.

The temporal profile offers a view of the "forest" (course of illness) as well as the "individual trees"
(components). The relationship of all components over the course of the illness is a great and
inestimable value for correct diagnosis.

, ReJerences:
1. A physiological approach to the clinical examination, 3'd edition by Judge and Zuideema
2. Physical diagnosis by Elliot Hochstein and Al Rubin, Copyright 1964by McGraw Hill.
3. Bates' Guide to Physical Examination and History Taking, 12th edition

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