A Practical Guide to Clinical Medicine
A comprehensive physical examination and clinical education site for medical students and other health care professionals
|Introduction||Breast Exam||Write Ups|
|History of Present Illness||The Pelvic Examination||The Oral Presentation|
|The Rest of the History||Male Genital/Rectal Exam||Outpatient Clinics|
|Review of Systems||The Upper Extremities||Inpatient Medicine|
|Vital Signs||The Lower Extremities||Clinical Decision Making|
|The Eye Exam||Musculo-Skeletal Exam||Physical Exam Lecture Series|
|Head and Neck Exam||The Mental Status Exam||A Few Thoughts|
|The Lung Exam||The Neurological Exam||Commonly Used Abbreviations|
|Cardiovascular Exam||Physical Exam Check Lists||References|
|Exam of the Abdomen||Medical Links|
The "daVinci Anatomy Icon" denotes a link to related gross anatomy pictures.
Past Medical History: Start by asking the patient if they have any medical problems. If you receive little/no response, the following questions can help uncover important past events: Have they ever received medical care? If so, what problems/issues were addressed? Was the care continuous (i.e. provided on a regular basis by a single person) or episodic? Have they ever undergone any procedures, X-Rays, CAT scans, MRIs or other special testing? Ever been hospitalized? If so, for what? It's quite amazing how many patients forget what would seem to be important medical events. You will all encounter the patient who reports little past history during your interview yet reveals a complex series of illnesses to your resident or attending! These patients are generally not purposefully concealing information. They simply need to be prompted by the right questions!
Past Surgical History: Were they ever operated on, even as a child? What year did this occur? Were there any complications? If they don't know the name of the operation, try to at least determine why it was performed. Encourage them to be as specific as possible.
Medications: Do they take any prescription medicines? If so, what is the dose and frequency? Do they know why they are being treated?* Medication non-compliance/confusion is a major clinical problem, particularly when regimens are complex, patients older, cognitively impaired or simply disinterested. It's important to ascertain if they are actually taking the medication as prescribed. This can provide critical information as frequently what appears to be a failure to respond to a particular therapy is actually non-compliance with a prescribed regimen. Identifying these situations requires some tact, as you'd like to encourage honesty without sounding accusatory. It helps to clearly explain that without this information your ability to assess treatment efficacy and make therapeutic adjustments becomes difficult/potentially dangerous. If patients are, in fact, missing doses or not taking medications altogether, ask them why this is happening. Perhaps there is an important side effect that they are experiencing, a reasonable fear that can be addressed, or a more acceptable substitute regimen which might be implemented. Don't forget to ask about over the counter or "non-traditional" medications. How much are they taking and what are they treating? Has it been effective? Are these medicines being prescribed by a practitioner? Self administered?
* You'll be surprised to learn how many patients don't know the answers to these questions. Encourage them to keep an up to date medication list and/or write one out for them. When all else fails, ask the patient to bring their meds with them when they return or, if they are in-patients, see if a family member/friend can do so for them.
Allergies/Reactions: Have they experienced any adverse reactions to medications? The exact nature of the reaction should be clearly identified as it can have important clinical implications. Anaphylaxis, for example, is a life threatening reaction and an absolute contraindication to re-exposure to the drug. A rash, however, does not raise the same level of concern, particularly if the agent in question is clearly the treatment of choice.
Smoking History: Have they ever smoked cigarettes? If so, how many packs per day and for how many years? If they quit, when did this occur? The packs per day multiplied by the number of years gives the pack-years, a widely accepted method for smoking quantification. Pipe, cigar and chewing tobacco use should also be noted.
Alcohol: Do they drink alcohol? If so, how much per day and what type of drink? Encourage them to be as specific as possible. One drink may mean a beer or a 12 oz glass of whiskey, each with different implications. If they don't drink on a daily basis, how much do they consume over a week or month?
Other Drug Use: Any drug use, past or present, should be noted. Get in the habit of asking all your patients these questions as it can be surprisingly difficult to accurately determine who is at risk strictly on the basis of appearance. Remind them that these questions are not meant to judge but rather to assist you in identifying risk factors for particular illnesses (e.g. HIV, hepatitis). In some cases, however, a patient will clearly indicate that they do not wish to discuss these issues. Respect their right to privacy and move on. Perhaps they will be more forthcoming at a later date.
Obstetric (where appropriate): Have they ever been pregnant? If so, how many times? What was the outcome of each pregnancy (e.g. full term delivery; spontaneous abortion; therapeutic abortion).
Sexual Activity: This is an uncomfortable line of questioning for many practitioners. However, it can provide important information and should be pursued. As with questions about substance abuse, your ability to determine on sight who is sexually active (and in what type of activity) is rather limited. By asking all of your patients these questions, the process will become less awkward. Do they participate in intercourse? With persons of the same or opposite sex? Are they involved in a stable relationship? Do they use condoms or other means of birth control? Married? Health of spouse? Divorced? Past sexually transmitted diseases? Do they have children? If so, are they healthy? Do they live with the patient?
Family History: In particular, you are searching for heritable illnesses among first or second degree relatives. Most common, at least in America, are coronary artery disease, diabetes and certain malignancies. Patients should be as specific as possible. "Heart disease," for example, includes valvular disorders, coronary artery disease and congenital abnormalities, of which only coronary disease has genetic implications. Find out the age of onset of the illnesses, as this has prognostic importance for the patient. For example, a father who had an MI at age 70 is not a marker of genetic predisposition while one who had a similar event at age 40 certainly would be. Also ask about any unusual illnesses among relatives, perhaps revealing evidence for rare genetic conditions.
Work/Hobbies/Other: What sort of work does the patient do? Have they always done the same thing? Do they enjoy it? If retired, what do they do to stay busy? Any hobbies? Participation in sports or other physical activity? Where are they from originally? These questions do not necessarily reveal information directly related to the patient's health. However, it is nice to know something non-medical about them. This may help improve the patient-physician bond and relay the sense that you care about them as a person. It also gives you something to refer back to during later visits, letting the patient know that you paid attention and really remember them.
Military Service: For obvious reasons, serving in the armed forces can be an important period in someone's life. In addition, inquiring about physical trauma, mental health issues (PTSD, depression, substance abuse), and unusual exposures (toxins, infections) may reveal important information.
In recounting their history, patient's frequently drop clues that suggest issues meriting further exploration. If, for example, they are taking anti-hypertensive or anti-anginal medications yet made no mention of cardiac disease, additional history taking would be in order. Furthermore, if at any time you uncover information relevant to the chief complaint don't be afraid to revisit the HPI.
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