There are several basic pieces of information that can be joined to establish the prope diagnosis by the clinician. These are:
A) History (which must be accurate, skillfully elicited, carefully interpreted, and coherently expressed).
B) Physical Examination (which should build on the existing information and /provide clues for obtaining additional history).
C) Ancillary data (routine and special studies, consultations, etc.).
D) Observations of the Course of the illness (usually less expensive and more rewarding than extensive excursions in the use of ancillary studies, e.g., lab).
Our basic thesis is that the vast majority of clinical problems should and can be resolved by the effective use of the History and Physical Examination.
In most cases the History should be and is the most productive. You will find this conclusively and objectively demonstrated when dealing with patients about whom no history can be obtained.
To put it another way, the diagnosis should be clear based on the Present illness and related points of the History most of the time. In fact, if the diagnosis is not apparent at the end of the History and the Physical Examination, there is little likelihood that such will emerge by the use of ancillary data/or special studies.
Laboratory studies should be viewed and used primarily to confirm a diagnosis rather than make one. Furthermore, experience has taught us that thoughtful observation of the patient and his or her illness can be the most effective tool of complex, particularly chronic, problems.
HISTORY
CHIEF COMPLAINT
This is the first sentence of the write-up and identifies the patient by age and sex and also briefly characterizes the most important complaint in the patient’s own words including its duration in hours, days, months or years. The Chief Complaint is the ‘marquee’ outside of the theater and should capture the essence of why the patient presented to the hospital or the physician for care. It sets up the remainder of the History and Physical and poses the questions that the remainder of the record will attempt to answer. It is a short and focused – ‘one liner’ or a single sentence. The Chief Complaint is typically one symptom although rarely a ‘symptom complex’ is used in the case for example of endocarditis or a connective tissue disease. The Chief Complaint is not a diagnosis, laboratory value, or anticipated treatment. It must be accurately defined in terms of its nature and duration. The patient’s own words are important; however, the physician must be primarily concerned with interpreting, translating, and formulating the “proper: Chief Complaint.
One must be always aware of the problem of semantics. For example, does “pooped out” mean muscular weakness shortness of breath, or simply a lack of desire for physical activity?
Examples of a Chief Complaint include:
A) This is the first
B) This 75-year-old white male was in his usual state of health until five hours prior to admission when he developed the acute onset of substernal chest discomfort.
Strategically and appropriately, placed adjectives may further enhance the Chief Complaint.
For example:
“This 25 year old white male presented with the Chief Complaint of shortness of breath over two weeks prior to admission.”
This Chief Complaint seems less directive and vaguer than one that reads: “This 25 year old white male homosexual was admitted with a two week history of shortness of breath.” Clearly one would think about Pneumocystis pneumonia in this latter Chief Complaint.
Similarly, a 55-year-old white male with a long history of cardiac disease who presents with a Chief Complaint of chest pain is more directive than simply a 55 year old white male who presents with four hours of chest pain as a Chief Complaint.
The physician may interpret the patient’s Chief Complaint. In other words, the complaint that may initially have brought the patient to the hospital may wind up not to be the major problem that is written about.
For example, a patient who has a complaint of sinus difficulties as a reason for coming to the doctor, but who on chest x-ray is found to have a lung cancer may end up with a Chief Complaint of increasing shortness of breath occurring over the past one month.
PRESENT ILLNESS
The process of history taking serves several purposes. Some of these are:
A) It begins to establish a level of “communication” and a relationship with the patient that will provide important insights into the functional and feeling status of the patients; this enhances one’s understanding of the patient as a person.
B) It must become the single most valuable source of diagnostic information.
C) It does provide some focus for the physical examination to be more intensive in certain areas.
D) It guides one’s selection of future studies of an ancillary nature.
E) It can elicit important information and provides direction for prevention/intervention of illness in the future.
The Present Illness therefore gives the relevant history of the major problem that will be dealt with during the admission. It is chronological starting from the onset of symptoms and ends when the patient is admitted to the hospital i.e. what was it that finally brought the patient to the hospital.
The Present Illness traces the development over time of all relevant symptoms and any stimulating or relieving factors that affect them and any remedies that were tried and their effects. It must include either during the text or at the end a listing of pertinent negative and positive symptoms. It should not however include laboratory or treatment rendered in an Emergency Room. It should be specific to and further describe the Chief Complaint. Certainly problems and symptoms should be “lumped” together and included if available data suggest that they share a common etiology or cause. However, do not include irrelevant symptoms in the Present Illness.
Rhetoric is important when writing up a History and Physical and good English should be rigorously practiced.
As relates to chronology in the Present Illness, this should not be written in terms of dates, but rather sentences should be front-ended by the time of onset of a symptom in terms of days, months, hours or years. For example, five hours prior to admission the patient developed the acute onset of right-sided chest pain. It is preferable not to have the time duration towards the end of a sentence but rather at the beginning.
There are several factors influencing the effectiveness and efficiency with which a physician obtains a history. These may include:
A) The presence or lack of an organized approach to collecting data which obviously depends on the proper use of a differential diagnosis during history taking.
B) The patient’s attitudes towards physicians, the illness, the specific physician involved, and other health personnel.
C) The physician’s attitude towards the patient, the type (age, sex, social status) of patient he/she is, the illness involved, etc.
D) The level of interest, warmth, and/or empathy that the physician displays towards the patient. Patients are quite perceptive and unusually sensitive to deviations from a genuinely open and honest approach.
E) The level of mutual respect. The physician should display a polite and honestly friendly concern in an intellectual and objective manner.
Above all, it must be stated that patients are never poor historians- only doctors are!
Overall, the timing, sequence, chronology, and proper language are the essential ingredients to a cogent Present Illness. In short, the Present Illness must add up to something that is identifiable as an illness. One must ask “does it add up to something that can be identified?” The following must be kept in mind.
A) Most diseases have a relatively constant and predictable natural history. Their expressions through patients in the form of illness become the Present Illness.
This expression of a disease will however vary from patient to patient presenting a challenge to the clinician in that it requires the ability to help the patient translate subjective complaints like diarrhea into objectively describable parameters. Pain must be fully described in terms of frequency, onset, relieving and exacerbating factors, etc. Symptoms such as shortness of breath described in terms of change in exercise tolerance, diarrhea in terms of volume and frequency of stools. Phlegm in terms of amount and color are all-important. Subjective historical expressions such as weakness, pain, strange sensations, flu, etc are generally imprecise. This presents a challenge to the clinician in that he has to help the patient translate the subjective complaints into objectively describable parameters. Weakness as a symptom for example can have many different meanings and can reflect respiratory failure, muscular weakness, or lack of desire. This must be fathomed out in the Present Illness.
PAST MEDICAL HISTORY
The Past Medical History may be subdivided into Pertinent Past Medical History and Past Medical History.
Pertinent Past Medical History tends to occur directly after the Present Illness if it directly pertains to it. This may include past cardiac events in a patient with a complaint of chest pain.
Otherwise, the Past Medical History lists all other important past medical events. It should be written in a list form not as a narrative. It gives a quick overview of significant health events and care. It should include the year of diagnosis of a medical problem or the year a surgical procedure was performed.
Developmental history for pediatric patients should also be noted.
MEDICATIONS
This should list dosage and schedule and should include over the counter medications. Simply stating “takes a water pill” is unacceptable. If the dosage is not known, contact the pharmacy to get the dosage.
ALLERGY / IMMUNIZATIONS
Specifically list allergies to medications. Also, list the reaction, if known. Remember that an individual may have an intolerance (e.g. GI upset to Erythromycin), that he/she may misperceive as an “allergy”. An intolerance may also be listed, but please label it as such.
Comments should be made regarding age appropriate immunizations.
SOCIAL HISTORY
A personal and social history should then be presented. In instances in which there are obvious interactions between the patient’s family and social situation and the acute illness (e.g., psychiatric problems), this information would have been presented as part of the HPI. The main goal of this section is to understand the patient as a person. Identification of potential problems and coping mechanisms for dealing with illness should be discussed and should include the following areas of emphasis:
A) Background: birthplace, family setting, cultural background, education, residences, jobs, significant travel.
B) Current Setting: health of spouse, other intimate relationships, family members, and living circumstances.
C) Occupation: type, security, satisfaction, finances, insurance.
D) Recreational hobbies and activities.
E) Quality of intimate relationships: number of, satisfaction with, sexual concerns.
F) Other social supports.
G) Health insurance and relevant personal financial information.
Example: The patient is married and lives with his wife and three children in their own home in Hilt,
Substance use: alcohol, tobacco, and illicit drugs.
FAMILY HISTORY
A screening for inheritable diseases: Allergies, Alcoholism, Birth Defects, Cancer, Depression, Diabetes Mellitus, Epilepsy, Gout, Hypertension, Heart Disease, Renal Disease, Stroke, TB.
ROS (Review of Systems)
If a specific organ system was already investigated in the HPI, you may simply write, “As noted in the HPI-see above”. Otherwise, you must list everything.
Simply writing “ROS” is non-contributory/unremarkable” is not acceptable at your present level of training. Remember that actual disease entities (e.g. glaucoma) belong in the PMH-Illness section.
The ROS is reserved for symptoms.
GENERAL
Weight change, weight loss, weakness, fatigue, fever, chills, rigors, night sweats
SKIN
Color change, eruptions, rash, pruritus, scaling, bruising, bleeding, lumps, sores, changes in hair color, texture of distribution, hare loss, changes in nail color, pitting, ridging, brittleness or abnormal curvature of the nails
HEAD AND NEUROPSYCHIATRIC
Headache, head injury, syncope, vertigo, focal weakness or paralysis, paresthesias, anaesthesias, convulsions, tremors, involuntary movements, disturbances of smell or taste, imbalance, difficulty in chewing or swallowing, difficulties in speech, loss of memory, atrophy, difficulty in walking, unexplained pain, incontinence of stool or urine, moodiness, insomnia, impotence, hallucinations, delusions, nervous breakdown, anhedonia
EYES
Loss of vision, tunnel vision, color blindness, diplopia, hemianopsia, trauma, glasses, redness, pain.
EARS
Hearing loss, tinnitus, vertigo, discharge, pain, hearing aid use, operations
NOSE
Coryza, rhinitis, epistaxis, trauma, discharge
THROAT, MOUTH AND TEETH
Hoarseness or change in voice, sore throats, bleeding gums, caries, extractions/dentures, dry mouth, and sore tongue
NECK NODES, ENDOCRINE
Lumps, swollen nodes, goiter, neck pain or stiffness, problems with growth, abnormal growth of head, hands, or feet; changes in hair distribution or shin color; intolerance of heat or cold, polydipsia, polyphagia, polyuria, excessive thirst or sweating
BREASTS: (Females)
Lactation, trauma, lumps, self-examination, nipple discharge or retraction, pain
RESPIRATORY
Chest pain, shortness of breath, wheezing, dyspnea of exertion, cough, sputum color and quantity, hemoptysis, tuberculosis exposure, last CXR or TB test
CARDIOVASCULAR
Palpitations, tachycardia, chest pain, orthopnea, paroxysmal nocturnal dyspnea, cyanosis, ascites, edema, claudication, cold extremities, murmur, last EKG
GASTROINTESTINAL
Change in appetite, dysphagia, dyspepsia, regurgitation, weight loss, nausea, belching, vomiting, hematemesis, food intolerance, flatulence, abdominal pain, jaundice, diarrhea, melena, hematochezia, change in stool color, consistency or caliber, hemorrhoids, constipation
URINARY
Change in color of urine, hematuria, dysuria, flank pain, nocturia, pyuria, frequency, urgency, hesitancy, retention, incontinence, decreased stream force
GENITAL (MALE)
Hernias, penile lesion or discharge, testicular pain or mass, self-exam, sexual preference, impotence
GENITAL (FEMALE)
Menstrual history including menarche, cycle length and regularity, duration and quantity of menses, LMP, PMP dysmenorrhea, intermenstrual bleeding and menopause; contact bleeding, postmenopausal bleeding, abnormal bleeding, vaginal discharge, leukorrhea, itching, sores, lesions; h/o DESCRIBED exposure; OB history including number of pregnancies, live births, still births, voluntary and spontaneous abortions, complications of pregnancy and delivery; contraception, contraception, sexual preference, sexual dysfunction, dysparunia
MUSCULOSKELETAL
Myalgias, arthralgais; stiffness, redness, warmth, swelling, or limitations of motion of joint; muscle weakness or atrophy; back pain, night cramps
PHYSICAL EXAMINATION
Several points concerning the Physical Examination merit emphasis:
A. The process should be:
1. Explained to the patient.
2. Comfortable for the patient and you.
3. Carried out with courtesy, gentleness and propriety.
4. Carried out in a sequence that is in your style but that will ensure that all systems are examined.
B. The Physical Examination should be carried out in a thorough and relevant fashion not neglecting other systems. It should be most intense in the area of suspicion as to the complaints and history obtained to that point.
C. Perhaps the most important consideration is to know one’s level of expertise in all aspects of the Physical Examination (e.g., how good are you at feeling a spleen or detecting early mitral stenosis? etc? etc?).
D. The Physical Examination should be used to test the hypothesis(es) formulated from the history in addition to screening for major and minor abnormalities.
The Physical Examination should be performed as completely as possible at the time of hospital admission. It should include at least the items below.
GENERAL
A general description of the patient should include signs of acute distress, general state of health and nutrition, and state of hydration. It may be helpful to note unusual behaviors or deformities here
VITAL SIGNS
Accurate vital signs are the responsibility of the resident (not the nurses) and must be recorded here including temperature, pulse, respiratory rate (count it yourself), blood pressure (repeat it yourself if abnormal), and measured weight. A stated height is acceptable in most adults.
SKIN
Examination of the naked patient is the rule. Presence of jaundice or other abnormal color, rashes, or lesions should be noted.
HEAD, EARS, EYES, NOSE, AND THROAT
Should include signs of head trauma, inspection of tympanic membranes, nasal passages and throat. Funduscopic exam should be attempted on every patient.
NECK
Must include mention of thyroid size and shape, neck pulses, JVD.
NODES
At a minimum must include mention of cervical and axillary nodes. Other areas must be checked when relevant.
CHEST
Must include mention of inspection and auscultation in the typical “IPPA” format. Use of accessory muscles of respiration may be mentioned here or in general description, along with retractions and flaring.
HEART
Must include at a minimum mention of auscultation including murmurs
BREASTS (FEMALES)
Must be done as part of a complete examination of a female. Should include mention of masses, skin or nipple changes.
ABDOMEN
Must include mention of bowel sounds, masses, hepatosplenomegaly and tenderness. Liver span in centimeters in the mid-clavicular line is mandatory.
GENITALIA (MALES)
Must be done as part of a complete examination of a male patient. Should include mention of hernias, scrotal masses, penile lesions or discharge.
PELVIC (FEMALES)
Must be done as part of a complete examination of a female patient. Minimum exam is bimanual palpation. Speculum exam with cultures must be done on any female with a fever, abdominal pain or a discharge, at the time of admission. Any female with a cervix must have a Pap smear before discharge unless one has been done within the last year.
RECTAL
Must be done on every patient as part of a complete examination. Should include a guiac test.
EXTREMITIES
Must include mention of peripheral pulses and edema, as well as any gross asymmetries or deformities.
NEUROLOGIC
Must include examination of mental status, motor, sensory, cranial nerves, coordination and reflexes.
INITIAL LAB AND X-RAY (ancillary data)
Ancillary data includes:
A) Laboratory data
B) Special studies
C) Consultations
Ancillary studies should not be used in a shotgun fashion or without consideration to costs/benefits ratio. Unfortunately, it is not infrequent that ancillary data is ordered prematurely and/out of context or without rational. Therefore, keep in mind the hypothesis that you are testing when you write orders. Literally, almost every patient that comes into the hospital should receive some baseline screening tests including urinalysis, CBC, lytes, BUN, creatine, and glucose. Other laboratories will be performed as appropriate to the case.
ASSESSMENT
The Assessment should be a brief statement of what diagnostic possibilities seem most likely. It may include a general statement of your approach to the diagnostic plan.
The History and Physical findings do not need to be reviewed here; however, your diagnostic thinking should be outlined and certainly will be evident in more detail in your plans for problem evaluation.
A discussion of the most probable cause and important alternative possibilities should be included.
The Assessment should not simply be a listing of problems identified. Relationships among problems are important to include in sections of the record.
PLANS
Plans for each problem should be divided into a) a diagnostic plan, b) a treatment plan and c) a patient education plan. The diagnostic plan should include a rationale for each test, showing how it can be expected to further define the nature of the problem.
An appropriate initial treatment plan should be presented. It should include the following aspects: 1) activity level; 2) diet; 3) medications; 4) other therapy (respiratory, PT/OT, etc) and 5) IV orders. The risks and benefits of procedures and treatments should be discussed.
The treatment plan should include patient education and should state what the patient was told. In addition, the resident should present any pertinent long-term implications of the major problems in terms of the patient’s 1) expected course; 2) self-image; 3) role in the family and the community: and 4) financial situation. The utilization of family and community resources in the patient’s ongoing care should be discussed.
Diagnostic tests that are planned should each be connected to the diagnosis being evaluated by that test.
Example: Rule out MI: Admit to coronary care unit. Daily serum enzyme determinations and EKGs. Chest X-ray to R/O CHF.
Example: Abdominal pain. Barium enema and sigmoidoscopy with possible biopsy to rule out inflammatory bowl disease.
Treatment should include all medications, surgery, physical therapy or other treatments being directed towards the problems at hand.
Example: Demerol 50mg. IM Q4H as needed for abdominal pain.
Example: Begin Inderal 40mg each morning for blood pressure.