The Medical Record

 Written document containing:

1. Medical history
2. Findings from the PE
3. Laboratory reports
4. Findings and conclusions from special exams
5. Findings and diagnoses of consultants
6. Diagnoses of the attending physician
7. Notes on treatment (meds, surgeries,
radiation, PT
8. Progress notes

The Medical Record

1. To assist the physician in making
diagnoses
2. To assist physicians, nurses and
others in the care and treatment of
the patient
3. To serve as a record for teaching
medicine and for clinical research

Medical Purposes
1. To document insurance claims for
the patient
2. To serve as legal proof in cases of
malpractice, claims for injury or
compensation, cases of poisoning,
cases of homicide

Legal Purposes
1. Author’s complete signature (affix
title to indicate status in the
medical organization)
2. Date of signing (month, day, year)
1. Physician’s locked office files
2. Medical record’s section of the
hospital
- “ privileged communication”

 Should not contain flippant or

derogatory remarks about the patient
or colleagues!

Custody
 Symptom
◦ Greek – “anything that has
befallen one”
◦ Abnormal sensation perceived by
the patient
 Signs
◦ Seen, felt or heard by the
examiner
 A prime symptom
 Prompts patient to seek medical care
 Directs attention to a specific
anatomic region
 Attributes of pain (PQRST)
◦ Provocative-Palliative Factors
◦ Quality
◦ Region/Radiation
◦ Severity
◦ Temporal characteristics

Diagnostic attributes of Pain

 Association of pain with
movement
 Can localize pain

Provocative-Palliative Factors
1. Bright, pricking – sharp, cutting,
knifelike
2. Burning – hot or stinging
3. Deep, aching – boring, pounding,
sore, heavy, constricting, gnawing
 Superficial pain – 1 & 2 (accurately
localized)
 Deep pain – 3 (more diffuse, difficult
to localize), persists longer e.g.
throbbing, cramping

3 Qualities of Pain
 Painis usually confined to one or
more anatomic regions which the
patient can point

Region/Radiation
 Measurement of intensity of pain
◦ Likened to some common
experiences
◦ Scale of 1 to 10
 Know the patient’s reaction to
pain (facial expression, bodily
postures, etc.)

Severity
 Total duration of pain
◦ Short – throbbing, boring, cramping,
shooting, aching
◦ Remissions – pain of organic disease
◦ Constant pain for many days –
psychoneurotic
◦ Seasonal pain (fall, spring)
 Time of pain
◦ Daytime pain
◦ Nighttime pain

Temporal Characteristics
 An account of the events in the
patient’s life that have relevance to
his/her mental and physical health
 Based on facts
 Supplied by patient or other
informant
 Offered spontaneously or by skillful
probing
Definition of the Medical
History
 Varied
 Totest if the history is sufficient,
ask yourself if you can picture
the patient’s lifestyle and how
his or her illness affects it.

Scope of the History

3 Quests
1. Searching for symptoms
2. Eliciting accurate quantitative
descriptions
3. Securing precise chronologies of
events

Interrogation in History-
Taking
• Private
• Attitude – unhurried, interested, sympathetic
• avoid discussing your own health
• write sparingly while patient talks
• gauge the patient's understanding of the language
• gauge whether patient is telling the truth or not

Conducting the interview

 Identifying Data
 Informant
 Reliability
 Chief Complaint/s
 Present Illness (PI)
 Past History
 Family History
 Personal & Social History
 Review of Systems
 Physical Examination
Sequence of Components in the
Medical History
 Patient’s Name (complete)
 Age/Gender
 Marital status
 Occupation
- Sheds light on social status, physical exertion,
psychologic trauma, exposure to noxious agents and other
conditions that cause disease

-Address (complete)
◦ May help with same name
-Birth date and Age
◦ Comparison from previous visit
◦ May help with same name
-Place of Birth
◦ incidence of disease
-Nationality & Race
◦ incidence of disease

Identifying Data
 History of symptoms begins with this
 One or more symptoms causing MAJOR
discomfort
 state the duration
 Stated in patient’s own words (as words
or phrases)
 NOT diagnosis
 Serve as clues in investigation
 To remind you why patient came to seek
treatment

Chief Complaint/s
 Heart of the diagnostic history
 Written as chronologic narrative with complete
sentences in good English
 Symptoms accurately described
 Use open-ended questions
 DO NOT accept diagnosis
 Pertinent and not subjective
•include the negatives
 Varies in length
 To test the completeness, ask yourself whether
they convey a clear picture of patient’s sufferings
amid their own surrounding

Present Illness (PI)

 Contains:
◦ Childhood illnesses
◦ Adult illnesses with dates
Medical, surgical, OB/GYN,
psychiatric
◦ Previous hospitalization
◦ Previous medications
•include ALLERGIES
◦ Operations and injuries
Past History
 Parents – age and health; or age at
death and causes
 Siblings – age and health; or cause
of death
 To determine familial tendency of the
disease
 Documents presence or absence of
specific illnesses in family (e.g. HPN,
CAD, etc.)

Family History
 Birthplace, places of residence, marital
history, family of origin, current household
 Gender preference (e.g. Heterosexual or
Homosexual)
 Personal interests and lifestyle
 social and economic status
◦ Educational level
 Habits (e.g. diet, smoking, drugs, coffee,
alcohol, sedatives, etc.)
 Advanced directives (e.g. DNR)

Personal & Social History

 Integument
◦ Color, texture, moisture, rashes, pruritus, bruising,
lesions
◦ Color, texture, growth, loss, distribution
◦ Color, brittleness, ridging, configuration
 Skeletal - Fractures, stiffness, pain, weakness,
atrophy
 Muscular
 Respiratory
◦ Dyspnea, wheezing, orthopnea, cough, pain
 Cardiovascular
◦ Chest pain, tightness, palpitations
 GI – appetite, weight changes vomiting, pain
 Genitourinary – frequency, pain, menstruation
 Nervous – cranial nerves
 Psychiatric

Review of Systems
• Progress notes
• S _ subjective data
• O – objective data
• A - assessments
• P - plans
• Discharge summary

Other parts of the medical record

 The objective of PE is to elicit signs
of the disease hypotheses
considered as a result of your history
and to evaluate abnormalities
unnoticed by the patient.
 Start with VS – BP, pulse, Temp,
height and weight
 Done by region

Physical Examination
 Involves the 5 senses
 Methods
◦ Inspection
◦ Palpation
◦ Percussion
◦ Auscultation

Physical Examination
 The initial act of PE
 Seeking physical signs by observing
the patient
 Least mechanical and hardest to
learn
 Yields the most physical signs

Inspection
 The act of feeling by sense of
touch
 Sensitive parts of the hand:
◦ Tactile sense
◦ Temperature sense
◦ Vibratory sense
◦ Sense of position and consistency

Palpation
 Method of examination in which
the surface of the body is struck
to emit sounds that vary in
quality according to the density
of the underlying tissues

Percussion
 the
act of hearing to obtain
physical signs

Auscultation
 General Appearance
 HEENT
 Neck
 Lungs
 Heart
 Abdomen
 Extremities
 Genitourinary
 Cerebrum
 Cerebellum
Physical Examination
 Welldressed
 Education

General Appearance
 Jugular vein
 Lymph nodes
 lesions

Neck
 Retractions
 Lesions
 Breath sounds
 Crepitus

Chest
 Thrill
 Heave
 Abnormal heart sounds
 Apex

Heart
Abdomen
 Lesions
 Abnormal structures

Extremities
Cranial Nerves
 Sense of smell
 Patency
 Use something that is not
noxious e.g. ammonia
 Familiar smell E.g. coffee,
tobacco, peppermint etc

Olfactory nerve (CN I)

 Visual acuity
◦ Far & near
 Snellen’s chart
 Visual field
◦ Confrontation method
 Colorvision
 Movement
 Dark & light vision

Optic nerve (CN II)

 CN III, IV, VI
 Test for Extra Ocular Muscles
(EOM)

Oculomotor, Trochlear, Abducens

 Has 3 divisions
◦ Ophthalmic
 Corneal reflex
◦ Maxillary
 Nose, eyelid, upper lip
◦ Mandibular
 Largest cranial nerve

Trigeminal Nerve (CN V)

 Nasolabial folds
 Smile
 Close eye tightly

Facial nerve (CN VII)

 A.k.a.Vestibulocochlear nerve
 Sense of hearing
 Note for Nystagmus

Auditory nerve (CN VIII)

 Note for deviation of the uvula
◦ Deviates in the strong side
 Testthe Gag reflex
 Hoarseness

Glossopharyngeal nerve (CN IX) and

Vagus nerve (CN X)
 Testthe Trapezius and SCM
 Shoulder shrug and head turning

Spinal Accessory Nerve (CN XI)

 Test for deviation in the tongue
◦ Deviates towards the weak side
 Test for lingual speech (R’s)

Hypoglossal nerve (CN XII)