Summary title:
Structured system review:
A 40 years old man with abdominal pain since 3 years
Disclaimer:
This is a HIPAA de-identified open-online-patient-record with initial information in patient's voice, posted here early winter 2015 after collecting informed patient consent (form downloadable here ) by LNMCH research assistant and patient-information-communication-executive for a discussion (scroll to the bottom) initiated by patient's primary care physician in-charge:
RECORD MANAGED BY: KULDEEP GUPTA (research assistant and patient-information-communication-executive LNMCH)This is a HIPAA de-identified open-online-patient-record with initial information in patient's voice, posted here early winter 2015 after collecting informed patient consent (form downloadable here ) by LNMCH research assistant and patient-information-communication-executive for a discussion (scroll to the bottom) initiated by patient's primary care physician in-charge:
Patient ID: PIPER462LONGUM
Narrative history in patient's voice:
Structured system review:
Check list for Systems Review
GENERAL
Fatigue/malaise, Fever/rigors/night sweats, Weight/appetite, Skin: rashes/bruising
Sleep disturbance
CARDIOVASCULAR
Chest pain/angina
Shortness of breath (including on exercise)
Orthopnoea
Paroxysmal nocturnal dyspnoea
Palpitations
Ankle swelling
RESPIRATORY
Chest pain, Shortness of breath/wheeze, Cough/sputum/haemoptysis, Exercise tolerance
GASTROINTESTINAL
Appetite/weight loss
Dysphagia
Nausea/vomiting/haematemesis
Indigestion/heart burn
Jaundice
Abdominal pain
Bowels: change/constipation/diarrhoea/
description of stool/blood/mucus/flatus
MUSCULOSKELETAL
Pain/swelling/stiffness – muscles/joints/
back
Restriction of movement or function
Power
Able to wash and dress without difficulty
Able to climb up and down stairs
GENITO-URINARY
Frequency/dysuria/nocturia/polyuria/oliguria
Haematuria
Incontinence/urgency
Prostatic symptoms
Impotence
Menstruation (if appropriate):
menarche (age at onset)
duration of bleeding, periodicity
menorrhagia (blood loss)
dysmenorrhoea, dyspareunia
menopause, post-menopausal bleeding
CENTRAL NERVOUS SYSTEM
Headaches
Fits/faints/loss of consciousness
Dizziness
Vision – acuity, diplopia
Hearing
Weakness
Numbness/tingling
Loss of memory/personality change
Anxiety/depression
ENDOCRINE
Menstrual abnormalities
Hirsutism/alopecia
Abnormal secondary sexual features
Polyuria/polydipsia
Amount of sweating
Quality of hair
SKIN
Rash
Pruritus
Acne
(reference for above and below: https://www.ucl.ac.uk/pcph/undergrad/cbt/year4/history-and-examination): Originally by Kate Chatten, Mary Howe, Gillian Marks, Tom Smith and Dr Lorraine
Noble. Edited and updated by Henry Tufton, Dr Alison Sturrock and Dr Deborah Gill
© Division of Medical Education 2012
DETAILED SYSTEMS REVIEW:
Respiratory History
• Record the date and time the history was taken.
• Name, Age, Occupation(s)
Presenting Problem/Complaint
There are seven main respiratory symptoms to ask about:
1. Cough (character)
2. Sputum (colour, amount)
3. Haemoptysis (colour, amount)
4. Wheeze (diurnal variation?)
5. Chest Pain (site, radiation, character)
6. Shortness of breath (exercise tolerance, orthopnoea)
7. Systematic symptoms e.g. night sweats and weight loss
For each symptom describe:
• Onset
• Duration
• Course
• Severity
• Precipitating Factors
• Relieving factors
• Associated features
• Previous episodes
Past Medical History
e.g. Tuberculosis, atopy
Drug History
Allergies, inhalers, nebuliser, home oxygen
Social History
Smoking history-measured in pack years
Contact with animals/pets
Presence of stairs in or leading into flat/house
Hobbies
Who/how is shopping done?
Family history
e.g. asthma/hayfever
Systemic Review
Cardiovascular History •
Record the date and time the history was taken. • Name, Age, Occupation(s) Presenting Problem/ Complaint
Remember the 8 questions you need to ask about each symptom?
There are 4 main cardiovascular symptoms:
1. Chest pain (character, radiation)
2. Shortness of breath (exercise tolerance, orthopnoea, paroxysmal nocturnal dyspnoea)
3. Presence and extent of oedema (ankle, leg or sacral)
4. Palpitations (tap out rhythm, any dizziness or blackouts)
During the history consider (and ask about) the main risk factors for Ischaemic Heart Disease: 1. Smoking 2. Hypertension 3. Diabetes mellitus 4. Hyperlipidaemia 5. Family history
Past Medical History (may ask under presenting complaint) e.g. angina, myocardial infarction, bypass operation, rheumatic fever, stroke, intermittent claudication
Social History Smoking (pack years), alcohol,
Family History At what age did the relative have illness?
Drug History Allergies
Originally by Kate Chatten, Mary Howe, Gillian Marks, Tom Smith and Dr Lorraine Noble. Edited and updated by Henry Tufton, Dr Alison Sturrock and Dr Deborah Gill © Division of Medical Education 2012
Locomotor History
Main points to enquire about are:
1. Evolution of condition • Acute or chronic? • Associated events • Response to treatment
2. Current symptoms • Pain • Stiffness • Swelling • Pattern of joint involvement
3. Involvement of other symptoms • Skin, lung, eye or kidney symptoms • Malaise, weight loss, fevers or night sweats?
4. Impact of lifestyle • Patient’s needs/ aspirations • Ability to adapt with functional loss Pain History
If the presenting complaint is pain (most types of pain e.g. chest, abdominal etc) the main points to elicit can easily be remembered using the mnemonic ‘SOCRATES’.
All of these should be documented in the HPC.
• S -site • O -onset • C -character • R -radiation • A - associations • T -timing • E -exacerbating & relieving factors • S -severity Remember to ask about use of medication for pain relief.
Clinical Images:
Cardiovascular History •
Record the date and time the history was taken. • Name, Age, Occupation(s) Presenting Problem/ Complaint
Remember the 8 questions you need to ask about each symptom?
There are 4 main cardiovascular symptoms:
1. Chest pain (character, radiation)
2. Shortness of breath (exercise tolerance, orthopnoea, paroxysmal nocturnal dyspnoea)
3. Presence and extent of oedema (ankle, leg or sacral)
4. Palpitations (tap out rhythm, any dizziness or blackouts)
During the history consider (and ask about) the main risk factors for Ischaemic Heart Disease: 1. Smoking 2. Hypertension 3. Diabetes mellitus 4. Hyperlipidaemia 5. Family history
Past Medical History (may ask under presenting complaint) e.g. angina, myocardial infarction, bypass operation, rheumatic fever, stroke, intermittent claudication
Social History Smoking (pack years), alcohol,
Family History At what age did the relative have illness?
Drug History Allergies
Originally by Kate Chatten, Mary Howe, Gillian Marks, Tom Smith and Dr Lorraine Noble. Edited and updated by Henry Tufton, Dr Alison Sturrock and Dr Deborah Gill © Division of Medical Education 2012
Locomotor History
Main points to enquire about are:
1. Evolution of condition • Acute or chronic? • Associated events • Response to treatment
2. Current symptoms • Pain • Stiffness • Swelling • Pattern of joint involvement
3. Involvement of other symptoms • Skin, lung, eye or kidney symptoms • Malaise, weight loss, fevers or night sweats?
4. Impact of lifestyle • Patient’s needs/ aspirations • Ability to adapt with functional loss Pain History
If the presenting complaint is pain (most types of pain e.g. chest, abdominal etc) the main points to elicit can easily be remembered using the mnemonic ‘SOCRATES’.
All of these should be documented in the HPC.
• S -site • O -onset • C -character • R -radiation • A - associations • T -timing • E -exacerbating & relieving factors • S -severity Remember to ask about use of medication for pain relief.
Clinical Images:
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