Medical History Taking Study Guide



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Medical History Taking Study Guide



   Author: Richard Rathe, MD / rrathe@dean.med.ufl.edu
Copyright: 1996 by the University of Florida
 Location: http://medinfo.ufl.edu/year1/bcs/clist/history.html
  Created: September 25, 1996   Modified: November 10, 1997

NOTE: This checklist summarizes concepts presented elsewhere in the course. Refer to the lecture slides and handouts for additional detail.


General Considerations


Remember that there are two halves to each interview, patient-centered and physician-centered.

Physician-Centered

Patient-Centered

Physician's Agenda

Patient's Agenda

Biomedical Focus

Symptom Focus

Physician Gathers Data

Patient Tells Story

Outline for the interview:

  • The Opening

    • Chief Complaint(s) (CC) [1]

  • History of Present Illness (HPI)

    • Primary [1]

    • Secondary (focused ROS)

    • Tertiary (focused PMH)

  • Review of Systems (ROS)

  • Past Medical History (PMH)

Opening the Interview

It is important to begin each medical interview with a patient-centered approach. [2] [p10] [3]


  1. Set the Stage

    • Welcome the patient - ensure comfort and privacy

    • Know and use the patient's name - introduce and identify yourself

  2. Set the Agenda

    • Use open-ended questions initially

    • Negotiate a list of all issues - avoid detail! [4]

      • Chief complaint(s) and other concerns

      • Specific requests (i.e. medication refills)

    • Clarify the patient's expectations for this visit - ask the patient "Why now?"

  3. Elicit the Patient's Story

    • Return to open-ended questions directed at the major problem(s)

    • Encourage with silence, nonverbal cues, and verbal cues

    • Focus by paraphrasing and summarizing

  4. Make the Transition

    • Summarize the interview up to that point

    • Verbalize your intention to make a transition to the physician-centered interview

History of Present Illness

Primary History


You should always begin the physician-centered phase of the interview with "WH" questions (where? what? when?) directed at the chief complaint(s). Build on the information the patient has already given you. Flesh out areas of the story you don't fully understand. Try to quantify whenever possible (pain on a scale of 1 to 10, number of days instead of "a while," etc.). Be as specific as possible and try to record what the patient says accurately, without interpretation. Address as many of these details as appropriate: [p3]

  1. Location

  2. Radiation

  3. Quality

  4. Quantity

  5. Duration


  6. Frequency

  7. Aggravating Factors

  8. Relieving Factors

  9. Associated Symptoms

  10. Effect on Function

Secondary History


The secondary history expands on the primary history, especially any associated symptoms. It is useful to think of the secondary history as a focused review of systems (see below). These questions often bring out information that supports a certain diagnosis or helps you gauge the severity of the disorder. Unlike the primary history, a certain amount of interpretation (and experience) is necessary. Here are some examples:

Headache

Ask about nausea and vomiting.

Ask about visual changes.

Ask about the relationship with stress, work, week-ends, and emotions.



Ear Problems

Ask about hearing loss or ringing in the ears.

Ask about dizziness or vertigo.

Tertiary History


The tertiary history brings in elements of the past medical history (see below) that have direct bearing on the patient's condition. By the time you get to the tertiary history you may already have a good idea of what might be going on. (This will be fine tuned by the physical exam.) Here are some examples:

Any HEENT or Chest Disorder

Does the patient smoke? How much? How long?

For children, does someone smoke in the home?

Breast Problems

Is there a family history of breast cancer?



Abdominal Pain

Does the patient smoke? How much? How long?

How much alcohol does the patient consume?

Prior surgery? Has the appendix been removed?



Chest Pain

Does the patient smoke? How much? How long?


Did the patient's parents die of a heart attack? At what ages?

Review of Systems


The review of systems is just that, a series of questions grouped by organ system including: [p5]

  1. General/Constitutional

  2. Skin/Breast

  3. Eyes/Ears/Nose/Mouth/Throat

  4. Cardiovascular

  5. Respiratory

  6. Gastrointestinal

  7. Genitourinary

  8. Musculoskeletal

  9. Neurologic/Psychiatric

  10. Allergic/Immunologic/Lymphatic/Endocrine

Past Medical History


The past medical history is essentially background information related to the patient's health and well being. A brief past medical (and social) history often includes these elements: [p4]

  1. Allergies and Reactions to Drugs (What happened?)

  2. Current Medications (Including "Over-the-Counter")

  3. Medical/Psychiatric Illnesses (Diabetes, Hypertension, Depression, etc.)

  4. Surgeries/Injuries/Hospitalizations (Appendectomy, Car Accident, etc.)

  5. Immunizations

  6. Tobacco/Alcohol/Drug Use

  7. Reproductive Status for Females

  8. Birth History/Developmental Milestones for Children

  9. Marital/Family Status

  10. Occupation/Exposures


Notes

  1. A minimal interview consists of the chief complaint and primary history of present illness. The other elements may be selectively omitted as circumstances dictate. For example, a complete review of systems is often not necessary or desirable in the context of a focused evaluation.


  2. Adapted from workshop materials provided by Robert C. Smith, MD - used with permission.

  3. Page numbers refer to Barbara Bates' A Guide to Physical Examination and History Taking, Sixth Edition , published by Lippincott in 1995.

  4. It is extremely important to avoid detail (where, what, when) questions at this point. You should feel comfortable that all major issues are identified before proceeding. Remember that the patient has control of the patient-centered interview.

Vital Signs




   Author: Richard Rathe, MD / rrathe@dean.med.ufl.edu
Copyright: 1996 by the University of Florida
 Location: http://medinfo.ufl.edu/year1/bcs/clist/vitals.html
  Created: June 1, 1996   Modified: November 10, 1997


Equipment Needed

General Considerations


  • The patient should not have had alcohol, tobacco, caffeine, or performed vigorous exercise within 30 minutes of the exam.

  • Ideally the patient should be sitting with feet on the floor and their back supported. The examination room should be quiet and the patient comfortable.

  • History of hypertension, slow or rapid pulse, and current medications should always be obtained.

Temperature


Temperature can be measured is several different ways:

  • Oral with a glass, paper, or electronic thermometer (normal 98.6F/37C) [p129] [1]


  • Axillary with a glass or electronic thermometer (normal 97.6F/36.3C)

  • Rectal or "core" with a glass or electronic thermometer (normal 99.6F/37.7C)

  • Aural (the ear) with an electronic thermometer (normal 99.6F/37.7C)

Of these, axillary is the least and rectal is the most accurate.

Respiration


  1. Best done immediately after taking the patient's pulse. Do not announce that you are measuring respirations. [p129, p237] [2]

  2. Without letting go of the patients wrist begin to observe the patient's breathing. Is it normal or labored? [p252]

  3. Count breaths for 15 seconds and multiply this number by 4 to yield the breaths per minute.

  4. In adults, normal resting respiratory rate is between 14-20 breaths/minute. Rapid respiration is called tachypnea.

Pulse


  1. Sit or stand facing your patient. [p274]

  2. Grasp the patient's wrist with your free (non-watch bearing) hand (patient's right with your right or patient's left with your left). There is no reason for the patient's arm to be in an awkward position, just imagine you're shaking hands.

  3. Compress the radial artery with your index and middle fingers.

  4. Note whether the pulse is regular or irregular:
    • Regular - evenly spaced beats, may vary slightly with respiration [p300]


    • Regularly Irregular - regular pattern overall with "skipped" beats

    • Irregularly Irregular - chaotic, no real pattern, very difficult to measure rate accurately

  5. Count the pulse for 15 seconds and multiply by 4.

  6. Count for a full minute if the pulse is irregular. [3]

  7. Record the rate and rhythm.

Interpretation


  • A normal adult heart rate is between 60 and 100 beats per minute (see below for children).

  • A pulse greater than 100 beats/minute is defined to be tachycardia. Pulse less than 60 beats/minute is defined to be bradycardia. Tachycardia and bradycardia are not necessarily abnormal. Athletes tend to be bradycardic at rest (superior conditioning). Tachycardia is a normal response to stress or exercise.

Blood Pressure


  1. Position the patient's arm so the anticubital fold is level with the heart. Support the patient's arm with your arm or a bedside table. [p277]

  2. Center the bladder of the cuff over the brachial artery approximately 2 cm above the anticubital fold. Proper cuff size is essential to obtain an accurate reading. Be sure the index line falls between the size marks when you apply the cuff. Position the patient's arm so it is slightly flexed at the elbow. [4]

  3. Palpate the radial pulse and inflate the cuff until the pulse disappears. This is a rough estimate of the systolic pressure. [5]

  4. Place the stetescope over the brachial artery. [6]

  5. Inflate the cuff to 30 mmHg above the estimated systolic pressure.
  6. Release the pressure slowly, no greater than 5 mmHg per second.


  7. The level at which you consistantly hear beats is the systolic pressure. [7]

  8. Continue to lower the pressure until the sounds muffle and disappear. This is the diastolic pressure. [8]

  9. Record the blood pressure as systolic over diastolic ("120/70" for example).

Interpretation


  • Higher blood pressures are normal during exertion or other stress. Systolic blood pressures below 80 may be a sign of serious illness or shock.

  • Blood pressure should be taken in both arms on the first encounter. If there is more than 10 mmHg difference between the two arms, use the arm with the higher reading for subsequent measurements.

  • It is frequently helpful to retake the blood pressure near the end of the visit. Earlier pressures may be higher due to the "white coat" effect.

  • Always recheck "unexpected" blood pressures yourself.

Blood Pressure Classification in Adults

Category

Systolic

Diastolic

Normal

<140

<90

Isolated Systolic Hypertension

>140

<90

Mild Hypertension

140-159

90-99

Moderate Hypertension


160-179

100-109

Severe Hypertension

180-209

110-119

Crisis Hypertension

>210

>120

  • In children, pulse and blood pressure vary with the age. The following table should serve as a rough guide:

Average Pulse and Blood Pressure in Normal Children

Age

Birth

6mo

1yr

2yr

6yr

8yr

10yr

Pulse

140

130

115

110

103

100

95

Systolic BP

70

90


90

92

95

100

105


Notes


  1. Page numbers refer to Barbara Bates' A Guide to Physical Examination and History Taking, Sixth Edition , published by Lippincott in 1995.

  2. Unlike pulse, respirations are very much under voluntary control. If you tell the patient you are counting their breaths, they may change their breathing pattern. You cannot tell someone to "breath normally," normal breathing is involuntary.

  3. With an irregular pulse, the beats counted in any 30 second period may not represent the overall rate. The longer you measure, the more these variations are averaged out.

  4. You can not rely on pressures obtained using a cuff that is too small or too large. This is frequently a problem with obese or muscular adults where the regular cuff is too small. The pressure recorded will most often be 10, 20, even 50 mmHg too high! You often have to search high and low for a large cuff, but you will also "cure" a lot of high blood pressure.

  5. Maximum Cuff Pressure - When the baseline blood pressure is already known or hypertension is not suspected, it is acceptable in adults to inflate the cuff to 200 mmHg and go directly to auscultating the blood pressure. Be aware that there could be an auscultory gap (a silent interval between the true systolic and diastolic pressures).

  6. Bell or Diaphragm? - Even though the Korotkoff sounds are low frequency and should be heard better with the bell, it is often difficult to apply the bell properly in the anticubital fold. For this reason, it is common practice to use the diaphragm when taking blood pressure.


  7. Systolic Pressure - In situations where ausculation is not possible, you can determine systolic blood pressure by palpation alone. Deflate the cuff until you feel the radial or brachial pulse return. The pressure by auscultation would be approximately 10 mmHg higher. Record the pressure indicating it was taken by palpation (60/palp).

  8. Diastolic Pressure - If there is more than 10 mmHg difference between the muffling and the disappearance of the sounds, record all three numbers (120/80/45).


Cardiovascular Examination




   Author: Richard Rathe, MD / rrathe@dean.med.ufl.edu
Copyright: 1996 by the University of Florida
 Location: http://medinfo.ufl.edu/year1/bcs/clist/cardio.html
  Created: January 15, 1996   Modified: November 10, 1997


Equipment Needed


  • A Double-Headed, Double-Lumen Stethoscope

  • A Blood Pressure Cuff

  • A Moveable Light Source or Pen Light

General Considerations


  • The patient must be properly undressed and in a gown for this examination.

  • The examination room must be quiet to perform adequate auscultation.

  • Observe the patient for general signs of cardiovascular disease (finger clubbing, cyanosis, edema, etc.).

Arterial Pulses

Rate and Rhythm

  1. Compress the radial artery with your index and middle fingers. [p 274] [1]


  2. Note whether the pulse is regular or irregular. [p300]

  3. Count the pulse for 15 seconds and multiply by 4.

  4. Count for a full minute if the pulse is irregular. [2]

  5. Record the rate and rhythm.

Pulse Classification in Adults (At Rest)

Normal

Bradycardia

Tachycardia

60 to 100 bpm

less than 60 bpm

more than 100

Regular

Regularly Irregular

Irregularly Irregular

evenly spaced beats, may vary slightly with respiration

regular pattern overall with "skipped" beats

chaotic, no real pattern, very difficult to measure rate accurately [2]

[See below for children.]

Amplitude and Contour


  1. Observe for carotid pulsations. [p274]

  2. Place your fingers behind the patient's neck and compress the carotid artery on one side with your thumb at or below the level of the cricoid cartilage. Press firmly but not to the point of discomfort. [3]

  3. Assess the following:

    • The amplitude of the pulse.
    • The contour of the pulse wave.


    • Variations in amplitude from beat to beat or with respiration.

  4. Repeat on the opposite side.

Auscultation for Bruits


If the patient is middle aged or elderly, you should auscultate for bruits. A bruit is often, but not always, a sign of arterial narrowing and risk of a stroke. [p276] ++ [4]

  1. Place the bell of the stethoscope over each carotid artery in turn. You may use the diaphragm if the patient's neck is highly contoured.

  2. Ask the patient to stop breathing momentarily.

  3. Listen for a blowing or rushing sound--a bruit. Do not be confused by heart sounds or murmurs transmitted from the chest.

Blood Pressure


The patient should not have eaten, smoked, taken caffeine, or engaged in vigorous exercise within the last 30 minutes. The room should be quiet and the patient comfortable. [p277]

  1. Position the patient's arm so the anticubital fold is level with the heart.

  2. Center the bladder of the cuff over the brachial artery approximately 2 cm above the anticubital fold. Proper cuff size is essential to obtain an accurate reading. Be sure the index line falls between the size marks when you apply the cuff. Position the patient's arm so it is slightly flexed at the elbow.

  3. Palpate the radial pulse and inflate the cuff until the pulse disappears. This is a rough estimate of the systolic pressure. [6]

  4. Place the stetescope over the brachial artery. [5]

  5. Inflate the cuff to 30 mmHg above the estimated systolic pressure.

  6. Release the pressure slowly, no greater than 5 mmHg per second.
  7. The level at which you consistantly hear beats is the systolic pressure. [7]


  8. Continue to lower the pressure until the sounds muffle and disappear. This is the diastolic pressure. [8]

  9. Record the blood pressure as systolic over diastolic (120/70).

  10. Blood pressure should be taken in both arms on the first encounter. [9]

Interpretation


Blood Pressure Classification in Adults

Category

Systolic

Diastolic

Normal

<130

<85

High Normal

130-139

85-89

Mild Hypertension

140-159

90-99

Moderate Hypertension

160-179

100-109

Severe Hypertension

180-209

110-119

Crisis Hypertension

>210

>120

In children, pulse and blood pressure vary with the age. The following table should serve as a rough guide:


Average Pulse and Blood Pressure in Normal Children

Age

Birth

6mo

1yr

2yr

6yr

8yr

10yr

Pulse

140

130

115

110

103

100

95

Systolic BP

70

90

90

92

95

100

105

Jugular Venous Pressure


  1. Position the patient supine with the head of the table elevated 30 degrees. [p281] ++

  2. Use tangential, side lighting to observe for venous pulsations in the neck.
  3. Look for a rapid, double (sometimes triple) wave with each heart beat. Use light pressure just above the sternal end of the clavicle to eliminate the pulsations and rule out a carotid origin.


  4. Adjust the angle of table elevation to bring out the venous pulsation.



  5. Identify the highest point of pulsation. Using a horizontal line from this point, measure vertically from the sternal angle. [10]

  6. This measurement should be less than 4 cm in a normal healthy adult.

Precordial Movement


  1. Position the patient supine with the head of the table slightly elevated. [p285]

  2. Always examine from the patient's right side.

  3. Inspect for precordial movement. Tangential lighting will make movements more visible.

  4. Palpate for precordial activity in general. You may feel "extras" such as thrills or exaggerated ventricular impulses.

  5. Palpate for the point of maximal impulse (PMI or apical pulse). It is normally located in the 4th or 5th intercostal space just medial to the midclavicular line and is less than the size of a quarter.

  6. Note the location, size, and quality of the impulse.

Auscultation


  1. Position the patient supine with the head of the table slightly elevated. [p291]

  2. Always examine from the patient's right side. A quiet room is essential.

  3. Listen with the diaphragm at the right 2nd interspace near the sternum (aortic area).

  4. Listen with the diaphragm at the left 2nd interspace near the sternum (pulmonic area).
  5. Listen with the diaphragm at the left 3rd, 4th, and 5th interspaces near the sternum (tricuspid area). [11]


  6. Listen with the diaphragm at the apex (PMI) (mitral area).

  7. Listen with the bell at the apex.

  8. Listen with the bell at the left 4th and 5th interspace near the sternum. ++

  9. Have the patient roll on their left side. ++

    • Listen with the bell at the apex.

    • This position brings out S3 and mitral murmurs.

  10. Have the patient sit up, lean forward, and hold their breath in exhalation. ++

    • Listen with the diaphragm at the left 3rd and 4th interspace near the sternum.

    • This position brings out aortic murmurs.

  11. Record S1, S2, (S3), (S4), as well as the grade and configuration of any murmurs ("two over six" or "2/6", "pansystolic" or "crescendo").

Interpretation


Murmurs and Extra Sounds


Systolic Ejection

Innocent/Physiologic
Aortic/Pulmonic Stenosis



Pansystolic

Mitral/Tricusp Regurgitation
 


Systolic Click
Late Systolic

Mitral Valve Prolapse
 

Early Diastolic

Aortic Regurgitation



Mid Diastolic

Mitral/Tricusp Stenosis


Opening Snap
Diastolic Rumble

Mitral Stenosis



Ejection Sound

Aortic Valve Disease
 



S3

Normal in Children
Heart Failure



S4

Physiologic
Various Diseases


 

Murmur Grades

Grade

Volume

Thrill

1/6

very faint, only heard with optimal conditions

no

2/6

loud enough to be obvious

no

3/6

louder than grade 2


no

4/6

louder than grade 3

yes

5/6

heard with the stethoscope partially off the chest

yes

6/6

heard with the stethoscope completely off the chest

yes


Notes


  1. Page numbers refer to A Guide to Physical Examination and History Taking, Sixth Edition by Barbara Bates, published by Lippincott in 1995.

  2. With an irregular pulse, the beats counted in any 30 second period may not represent the overall rate. The longer you measure, the more these variations are averaged out.

  3. Avoid compressing both sides a the same time. This could cut off the blood supply to the brain and cause syncope. Avoid compressing the carotid sinus higher up in the neck. This could lead to bradycardia and depressed blood pressure.

  4. Additional Testing - Tests marked with (++) may be skipped unless an abnormality is suspected.
  5. Bell or Diaphragm? - Even though Korotkoff sounds are low frequency and should be heard better with the bell, it is often difficult to apply the bell properly to the anticubital fold. For this reason, it is common practice to use the diaphragm when taking the blood pressure.


  6. Maximum Cuff Pressure - When the baseline blood pressure is already known or hypertension is not suspected, it is acceptable in adults to inflate the cuff to 200 mmHg and go directly to auscultating the blood pressure. Be aware that there could be an auscultory gap (a silent interval between the true systolic and diastolic pressures).

  7. Systolic Pressure - In situations where ausculation is not possible, you can determine systolic blood pressure by palpation alone. Deflate the cuff until you feel the radial or brachial pulse return. The pressure by auscultation would be approximately 10 mmHg higher. Record the pressure indicating it was taken by palpation (60/palp).

  8. Diastolic Pressure - If there is more than 10 mmHg difference between the muffling and the disappearance of the sounds, record all three numbers (120/80/45).

  9. Pressure Differences - If there is more than 10 mmHg difference between the two arms, use the arm with the higher reading for subsequent measurements.

  10. Sternal Angle - The sternal angle is taken to be 5cm above the right atrium. A jugular pulse 10cm above the sternal angle equates to a central venous pressure of 15cm of water.

  11. Left Sternal Border - The left 3rd, 4th, and 5th interspaces are considered the tricuspid area and are referred to as the Lower Left Sternal Border or LLSB.

Prepared with assistance from Ira Gessner, MD




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