Johns Hopkins University School of Medicine National Youth Leadership Forum June 24, July 8, & July 22,

2003 The Art of History Taking The H&P (History and Physical Exam) is the cornerstone of medical diagnosis. Many physicians will tell you that the H&P will lead to the correct diagnosis 90% of the time. The focus of todays exercise is the history. The History: This is a patients medical story. The numerous parts of the history include: 1. History of Present Illness Your goal is to find out how exactly symptoms began, in what setting they arose, and how symptoms have evolved since initial onset. 2. Past Medical History What chronic illnesses does the patient have, if any? Is the patient taking any medication? Past hospitalizations? Does the patient have a primary care physician? Allergies? 3. Past Surgical History Past surgeries provides information about what medical problems the patient has had in the past and potential problems that might be in the patients future. 4. Family History What about the patients genetic make-up puts them at risk for particular disorders? 5. Social History This includes education level, occupation and occupational exposure, travel history, marital status, children, network of support, barriers to health care access, barriers to patient compliance, substance abuse history etc. 6. Sexual History Onset of sexual activity, number of partners, sex of partners, use of protective measures, history of any STDs etc. 7. Review of Symptoms This is an extensive laundry list of yes/no questions about every organ you can imagine. This is a great way to make sure you arent missing something. The Physical Examination: provides more information that helps in making the diagnosis. It involves 1

1. Vitals: How fast is the person breathing? What is their heart rate? What is their blood pressure? 2. Examine various body parts. In general your approach is to 1. Inspect: Describe what it looks like. Is it normal? If not what makes the appearance abnormal? 2. Percussion: This involves tapping on the body to determine if an area is hollow or solid. This is usually applied to the chest and abdomen. You are looking for things that deviate from normal. 3. Auscultation: This involves using your stethescope to listen to the heart, blood vessels, lungs and bowel 4. Palpation: using hands to examine the patient allows you to localize regions of pain, feel organs for size and texture, feel pulses, feel temperature etc.

REVIEW OF SYMPTOMS General: Skin: Eyes: Ears: Nose: Neck: Respiratory: weight rash vision hearing colds lumps cough Bronchitis Cardiovascular: high BP GI: appetite Swallowing Passing gas Urinary: dysuria Incontinence Genital Male: discharge Libido sores pain fatigue itching redness vertigo hay fever sore throat stiffness blood pneumonia orthopnea claudication nausea diarrhea polyuria UTI hernias vomiting constipation hematuria stones testicular pain function symptoms frequency self exam testicular masses satisfaction problems bleeding between periods ) interest dypsnea TB varicose veins abd. Pain sigmoidoscopy urgency wheezing edema bloating melena stool guaiac hesitancy asthma chest pain last chest x-ray thrombophlebitis pain emphysema murmurs heartburn lactose hemorrhoids nocturia stream STD sexual preference period regularity menopause age discharge pain tinnitus stuffiness bleeding gums goiter weakness dryness tearing earache fevers lumps double vision discharge sinus anosmia dysphagia chills nails glaucoma cataracts

nosebleed hoarseness

Mouth/Throat:teeth

sputum (color/quantity)

nocturnal dyspnea

Palpitations (rapid/skipped)

bowel movements

rectal bleeding

Gynecological: menarche age Breast lumps

duration

Last menstrual period

post menopausal bleeding

last mammogram (

Vaginal discharge #pregnancies ( contraception ( libido Musculoskel: joint pain Fractures Hematologic: anemia Endocrine: Neurologic: headache Numbness Tremor Psychiatric: Sleep: anxiety insomnia swelling )

itching #deliveries ( )

STD )

last pap smear ( #abortions ( function arthritis

pelvic pain

) pregnancy complications problems cramps

sexual preference prox. Weakness

interest

satisfaction gout

a.m. stiffness

back ache

functional limitations transfusions blackouts confusion tearfulness apnea lymphadenopathy seizures paralysis difficulty walking excessive thirst/hunger/urination/sweating memory loss psychosis bedtime (

easy bruising/bleeding heat/cold intolerance fainting dizziness tension head trauma tingling coordination depression

thyroid trouble

suicide attempts ) waketime ( )

non-restorative sleep snoring

The open-ended question should begin every discussion. If the patient is answering yes and no, chances are, you arent asking enough open-ended questions. Examples include: What brings you in today? Tell me more about your chest pain. What did your stool look like? What is your pain like? Avoid questions like: Was your stool black? Did you have a cold? Did you have a crushing pain in your chest? Obviously some questions have yes/no answers. For example: Do you have any allergies? Did you vomit? Do you have diarrhea? Whenever you elicit a positive response, it is important to learn more if you can. Specifically, you want to know what makes the symptom better or worse, how long it has been present, the severity, etc. A pneumonic for fleshing out a description of a symptom/pain is PQRST: Palliative factors Quality Region Severity Timing Do you have any allergies? Yes What are you allergic to? What kind of reaction did you have to drug X? Have you had to be hospitalized for this allergy?

Did you vomit? Yes Tell me more about your vomiting. How many times did you vomit? What did it look like? Did you eat anything just prior to vomiting? Do you have diarrhea? Yes For how long have you had diarrhea? Can you describe what you mean by diarrhea? How frequently do you have bowel movements? Realize that what seems like a clear yes/no question may not be. Ideally, even the most straightforward questions should be asked in an open-ended format if at all possible. Do you have any allergies? NO But I have had a bad reaction to penicillin, which went away after staying in the hospital for a week. Did you vomit? NO But I could taste the stuff in my stomach. I had stomach spasms and would have thrown up if I had eaten anything in the last week. Do you have diarrhea? NO But my stool has been loose for a month. This is different from diarrhea because I can hold it until Im ready to go.

Differential Diagnosis: Cough Acute cough: < 3 weeks Chronic cough: > 3 weeks or occurring frequently throughout the year. Pneumonia: 1-10 history of increasing cough, shortness of breath, a temperature as high as 104, tachycardia, increased respiratory rate, and an appearance of being sick. (1) Acute Bacterial Bronchitis: a productive acute cough yielding green, yellow, or rarely blood sputum often progressing from a viral-type illness (2) Postnasal drip and rhinitis: chronic cough associated with nasal congestion and morning cough. Cough may produce phlegm. (2) Chronic Bronchitis: characterized by a chronic cough productive of phlegm... on most days for 3 months of the year for two or more consecutive years without an otherwise defined acute cause. There is often a history of smoking. (1)

Pollutants: Cough with or without phlegm. (2) Smokers cough: Cough without phlegm, usually worse in the morning. (2) Asthma: is characterized by intermittent occurrence of cough, chest tightness, breathlessness, and wheezing with periods of being relatively symptom-free between attacks. (1)

Tumor: Hard to diagnose. May present as cough with bloody sputum in a person with exposure to pollutants or cigarette smoke. (2)

1. Stobo et al. Principles and Practice of Medicine. 2. JHUSOM Ambulatory Medicine Workbook 3. With permission from Gbemi Adeseun