Skills  Enhancement  I:  History  Taking  in  Adults  with  CVD   OS  213  

  Trans  B05  Exam  1  

Adult Cardiology Consultants 10/02/2018
 

OUTLINE   III.  HISTORY  OF  PRESENT  ILLNESS  

I.   General  Data   VIII.   Guidelines   adapted   from   HPI   begins   at   onset   of   symptoms   and   ends   upon   admission   at  
II.   Chief  Complaint   Preceptor  Guide   current  hospital.  
III.   History  of  Present  Illness   A.   Introduction  
•   Important   to   note   the   cardinal   manifestations   of   CV   diseases   to  
IV.   Review  of  Systems   B.   Definition  
formulate  differential  diagnoses  in  mind.  
V.   Past  Medical  History   C.   Process   of   Medical  
•   Ask  the  point  of  entry  in  the  hospital    
VI.   Family  History   History  
o   Was  the  patient  admitted  via  the  ER  or  OPD    
VII.   Personal  and  Social  History   D.   Checklist  in  History-­taking  
¨   If  via  OPD,  then  the  condition  of  the  patient  is  less  toxic  and  
Note:   Based   on   2021B   Trans.   Italicized   text   is   lifted   directly   from  
more  stable  than  those  admitted  vie  the  ER  
previous  trances  
o   If  the  patient  visited  multiple  hospitals/health  centers,  take  note  
 
of  management   and   impression  at  previous  hospital,  as  well  
Best  study  Trans  03  instead.  Blue  boxes  are  clinical  pearls  from  Dr.  
as  how  the  patient  was  transported.  
Llanes  and  Dr.  Hornelia.  This  trans  is  very  redundant  hahaha  sad  
  •   Should  be  complete,  concise  and  well-­written    
o   Can  be  used  by  the  patient  for  legal  purposes    
When   reporting,   start   with   general   data   and   then   give   history   o   Can  be  used  to  relay   a   story   to  others  who  may  manage  the  
chronologically   (eg:   “x  hours  prior   to   consult   to   current   hospital,   patient.    
…)   •   HPI  is  about  pattern-­recognition,  being  able  to  piece  in  together  
  the  different  symptoms  so  you  can  create  a  logical  impression.    
I.  GENERAL  DATA   •   Let  the  patient  tell  their  story  on  their  own  first    
•   Note   if   the   information   came   from   the   patient   or   the   o   Probing  questions  may  then  be  asked  after    
relative/companion  and  report  on  the  reliability  of  the  source.     o   Recap  everything    
•   Parts  of  the  general  data     o   Ask   leading   questions   at   the   end,   in   order   to   elicit   the  
o   Name     specific  details  that  we  need.    
o   Age   Baseline  profile    
o   Address   -­   Findings,  diagnoses,  and  lab  results  from  previous  
o   Date  of  Birth     checkups  can  be  presented  as  long  as  these  were  procured  
o   Sex   prior  to  admission    
o   Civil  status     -­   Include  any  diseases  relevant  to  the  complaint  such  as  
o   Place  of  origin     diabetes  and  hypertension    
¨   Have   the   patient   relay   the   chronology   of   his   or   her   -­   For  hypertension,  include  the  average  and  highest  recorded  
residence.  Ask  where  he  or  she  was  born,  if  they  transferred   BP    
or  migrated  to  another  place,  how  long  they  have  stayed  in   Include  functional  capacity  –  measure  of  how  independently  
each  place  and  the  like.     the  patient  can  move  without  tiring.  Very  important  for  
¨   Provides  a  clue  as  to  the  lifestyle  of  the  patient  or  provides  a   cardiovascular  cases!!!  
hint  as  to  where  the  patient  may  have  gotten  the  disease.    
•   Focus  on  the  chief  complaint  but  do  not  limit  your  thought  process  
o   Present  address    
•   Characterize  the  symptoms  with  the  following:    
o   Occupation    
o   P  –  Provoking  factors    
¨   Can  help  in  coming  up  with  analogies  to  explain  diseases  to   o   P  –  Palliative  factors    
them.     o   Q  -­  Quality    
¨   Example:  you  can  explain  cardiac  disease  to  a  mechanic  by   o   R  –  Region  &  Radiation    
likening  the  heart  to  an  engine     o   S  -­  Severity    
o   Educational  attainment   (Can   help   gauge   how   much   you   need   o   T  -­  Time  (Onset,  Duration,  Frequency)  
to   simplify   your   explanations.   Ie:   instead   of   orthopnea,   ask   o   O  –  Other  associated  symptoms  and  pertinent  findings    
“nakakahiga   po   ba   kayo   nang   maayos?   O   kailangan   niyo   po  
ba  ng  maraming  unan?”)   For   every   pain   felt   (chest,   abdomen,   head,   etc),   probe   for  
o   Religion   PPQRSTO.  
•   Always  ask  for  the  patient’s  ethnicity   •   Ask   the   patient   to   specify   or   elaborate   on   factors   that   are  
•   TOP  THREE  RISK  FACTORS:  Hypertensive?  Diabetic?  Smoker?     associated   with   a   disease   (e.g.   pagkahilo-­   ask   the   patient   to  
Do  not  include  the  name  of  the  patient  in  the  report.  Use  initials.   describe  the  quality)    
  Acute   symptoms   do   not   occur   overnight.   These   are   usually  
II.  CHIEF  COMPLAINT   preceded   by   other   symptoms   that   the   patient   has   disregarded  
•   Patient’s  main  reason  for  consult  +  medical  translation     (ie:  “pagod  lang  ako”).  
•   Preferably   verbatim,   but   an   exact   English   translation   is   •   Note  if  patient  has:  
acceptable  also   o   Paroxysmal   Nocturnal   Dyspnea:   most   discriminating   symptom  
•   If  more  than  one  chief  complaint  is  given  by  the  patient,  redirect  to   of  heart  failure    
the   most   pressing   concern.     (“Alin   po   ang   pinaka   o   Orthopnea   (needs   to   sleep   with   2-­3   pillows;;   indicative   of  
nakakapagpabagabag  sa  inyo?”)   pulmonary  congestion)    
•   Always  clarify  what  the  patient  means  on  her  complaint     o   Night  cough  and  fatigue    
•   Example:   In   syncope,   “natumba   ako”   (ano   pong   ibig   niyong   •   Women  of  age  60-­70  who  are  diabetic  may  have  pain  referred  to  
sabihin  sa  natumba  ako?)     the  epigastric  area    
  •   Symptoms  indicative  of  a  heart  attack:    
  o   Feeling  of  impending  doom/death    
o   Diaphoresis  (sweating)  –  due  to  hypersympathetic  response  to  
myocardial  infarction    

 
Trans Group 40: Sarsagat, Serrano A., Serrano D., Sevilla
 Skills  Enhancement  I:  History  Taking  in  Adults  with  CVD Page 2 of 3
  OS  213
o   Crescendo  intensity,  prolonged  pain,  dyspnea,  feeling  that  you   o   Sexual  behavior    
are  about  to  faint     o   Financial  status    
•   For  HPI,  state  the  basis  of  diagnosis  (diagnostic  tests  done  prior   o   Assess   patient's   activities   of   daily   livingl,   whether   he/she  
to   admission   e.g.   2D   Echo,   X-­ray,   etc)   as   well   as   treatment   performs   cardio,   strength   exercises  
regimens,  and  patient’s  compliance.     (running/swimming/etc)  or  lives  sedentary  lifestyle    
•   Take  note  of  any  medication  the  patient  is  taking  (prescribed,  self-­ •   Tread  carefully  for  sensitive  questions    
medicated,  herbal,  compliance,  etc)   •   For   smokers,   express   in   pack-­years.   (Assume   one   pack/day,  
•   When   taking   the   history,   as   you   ask   questions,   try   to   think   of   divided  by  365  days)    
differentials   already.   Ask   questions   from   open   (explore   possible   •   For   alcohol   drinkers,   quantify   how   many   bottles   of   alcohol   per  
differentials)   to   close   (when   you   already   have   a   clue   as   to   what   drinking  spree.    
the  patient  has  and  you  are  just  confirming  your  diagnosis).     •   Financial  status  is  related  to  patient  compliance.    
  o   Patients  will  not  take  medications  they  cannot  afford    
IV.  REVIEW  OF  SYSTEMS   o   Supervised   noncompliance   if   you   have   to   choose   only   the  
Ask  about  symptoms  grouped  by  system.   most  relevant  meds    
•   In  asking  about  the  use  of  illicit  drugs,  patients  have  the  tendency  
•   Components     to  deny  even  if  they  are  users.  Emphasize  that  as  the  doctor,  you  
o   General  (fatigue,  weakness,  fever)     have  to  know  in  order  to  treat  them  properly.    
o   Skin    
•   Practice  doing  the  interview  and  PE  in  a  systematic  and  concise  
o   Eyes,  Ears,  nose,  throat,  mouth    
manner.   This   is   very   important   when   the   patient   is   unstable  and  
o   Respiratory    
cannot  tolerate  stress  induced  by  the  interview  and  your  PE.    
o   Cardiovascular   (already   included   in   HPI   for   cardiovascular  
 
cases)  
From  previous  transes:  
o   Gastrointestinal    
o   Urinary     VII.  GUIDELINES  ADAPTED  FROM  PRECEPTOR  GUIDE  
o   Genito-­reproductive     A.  INTRODUCTION  
o   Breast     •   Evaluation  of  the  patient  with  known  or  suspected  cardiovascular  
o   MSK     disease   begins   with   a   directed   history   and   targeted   physical  
o   Endocrine     examination.    
o   Psychiatric     •   Taking   together   the   history,   information   from   the   physical  
•   Do   not   simply   ask   if   there   are   any   changes;;   try   to   probe   for   examination   and   any   investigations   or   tests,   this   should   provide  
specific   symptoms   that   could   be   present   in   the   system   being   all  the  information  needed  to  make  a  diagnosis.    
reviewed      
•   Note  both  positives  and  negatives     B.  DEFINITION  
•   From  2020B:  Individualization:  picking  out  symptoms  to  ask  about   •   Medical  History:  structured  assessment  conducted  to  generate  a  
which  will  help  with  the  diagnosis     comprehensive  picture  of  a  patient's'  health  and  health  problems.  
•   The   review   of   systems   is   a   roundup   of   symptoms   APART   from   It  includes  an  assessment  of:    
the  organ  systems  involved  in  the  chief  complaint  and  HPI.  Refine   o   patient's  current  and  previous  health  problems    
the   ROS   by   omitting   symptomatology   redundant   with   the   ones   o   current  and  previous  medical  treatment    
discussed  in  previous  sections.     o   the  patient's  health  in  general    
  o   Factors   which   might   affect   the   patient's   health   and   their  
V.  PAST  MEDICAL  HISTORY   response   to   prevention   or   treatment   of   health   problems   (e.g.  
•   Past  illnesses  of  the  patient     risk  factors,  lifestyle  issues)    
•   Previous  operations  and  injuries     ¨   Hypertension    
•   Medications     ¨   Diabetes  Mellitus    
•   Infectious  diseases     ¨   Smoking    
•   Previous  Hospitalizations  unrelated  to  current  case   ¨   Genetic  Predisposition    
o   Their  family’s  health    
•   Acute  hospital  admissions    
  •   Although   the   main   objective   is   to   have   enough   information   in  
order   for   us   to   arrive   in   a   diagnosis,   history   taking   includes  
VI.  FAMILY  HISTORY   questioning  about  the  patient's  perspective  of  their  situation    
•   Include  all  known  diseases  of  the  patient’s  family    
•   Patient's  perspective  affects:    
•   Include  spouse/their  side  of  the  family  only  if  infectious     o   their  response  to  information  and  recommended  treatment    
•   Any  unexplained  deaths  in  the  family     o   the  working  relationship  between  the  doctor  (or  team)  and  the  
•   Follows  the  same  pattern  as  the  patient’s  past  medical  history     patient    
•   If  a  relative  is  positive  for  any  of  the  diseases,  probe.  Don't  forget    
to  include  the  age  of  onset     C.  PROCESS  OF  MEDICAL  HISTORY  
•   If   the   patient   has   congenital   heart   disease,   ask   for   the   maternal   1.  Initiating  the  consultation  
history  and  the  context  of  birth  (e.g.  was  he  or  she  premature,  did  
•   Check  the  Setting    
the  mother  have  a  disease  etc.)    
•   Establish  the  initial  report    
Ask   about   malignancy,   thyroid   disease,   exposure   to   TB,  
•   Identify  the  reason  for  their  attendance    
infectious  diseases,  hypertension,  diabetes,  etc  in  the  family    
  2.  Gathering  the  information  
VII.  PERSONAL  AND  SOCIAL  HISTORY   •   Explore  the  patient's  problems    
•   Include:     •   Understand  the  patient's  perspective    
o   Marital  status    
o   Children     3.  Providing  structure  to  the  consultation  
o   Home  and  workplace    
•   Know  the  information  you  need    
o   Environment  (ex.  Urban,  provincial,  highly  polluted)    
•   Take  notes    
o   Typical  diet    
o   Smoking     •   Make  organization  of  the  history-­taking  overt    

Trans Group 40: Sarsagat, Serrano A., Serrano D., Sevilla

 
 Skills  Enhancement  I:  History  Taking  in  Adults  with  CVD Page 3 of 3
  OS  213
•   Attend  to  flow/  Follow  a  logical  sequence      
  4.  Past  Medical  History  
4.  Building  the  relationship   •   Previous  CVD    
•   Develop  support     •   Other  medical  conditions    
•   Involve  the  patient     •   Surgical  history    
•   Respond  to  the  patient's  needs      
•   Use  appropriate  non-­verbal  behavior     5.  Drug  History  
  •   Prescribed  medications    
5.  Ending  the  consultation   •   Over-­the-­counter  medications    
•   Tell  the  patient  that  you  covered  everything     •   Allergies    
•   Check  if  the  patient  has  nothing  more  to  add     •   Family  medical  history    
•   Summarize     •   Cardiovascular  diseases  in  the  family  (include  age  of  onset)    
•   Explain  the  next  step    
  6.  Personal  and  Social  History  
D.  CHECKLIST  IN  HISTORY  TAKING   •   Smoking/  Alcohol  intake/  recreational  drug  use    
1.  Introduction   •   Home  situation/  Level  of  functional  dependence    
•   Introduces  self  to  patient     •   Occupation    
•   Confirms  patient  details     •   Systemic  Review    
•   Establishes  presenting  complaint  upon  open  questioning   •   Screen  for  symptoms  in  other  parts  of  body    
   
2.  History  of  Present  Complaint   7.  Closing  the  consultation  
•   Palliating  /  Precipitating  factors     •   Thank  the  patient    
•   Quality  of  symptom     •   Summarizes  salient  points  in  the  history    
•   Regions  involved      
•   Severity     8.  Key  communication  skills  
•   Timing     •   Active  listening    
•   Other  associated  symptoms     •   Summarizing    
•   Ideas,  concerns  and  expectations     •   Signposting    
   
3.  Key  Symptoms   REFERENCES  
•   Chest  pain      
•   Dyspnea     END  OF  TRANS  
•   Palpitations      
•   Syncope      
•   Edema      
 
•   Decreased  exercise  tolerance    
 

Trans Group 40: Sarsagat, Serrano A., Serrano D., Sevilla