History taking and making notes

Making medical notes

All medical and paramedical professionals have a duty to record their input and care of patients in the case-notes. These form a permanent legal and medical document. There are some basic rules.

• Write in blue or black color.
• Date, time, and sign all entries: always identify retrospective entries.
• Be accurate.
• Make it clear which diagnoses are provisional.
• Abbreviations are lazy and open to misinterpretation; avoid them.
• Clearly document information given to patients and relatives.
• Avoid non-medical judgement of patients or relatives.

Basics

• Always record name, age occupation, method of presentation.
• Cover all the principal areas of medical history:
  • presenting complaint and past history relevant to it;
  • other past medical history, drug history, and systematic enquiry;
  • previous operations/allergies/drugs;
  • family history, social history, and environment.

Presenting complaint

This is a one- or two-word summary of the patient's main symptoms, e.g. abdominal pain, nausea and vomiting, swollen leg, PR bleeding.

• In emergency admissions do not write a diagnosis here (e.g. ischaemic leg). The diagnosis of referral may well turn out to be wrong.
• In elective admissions it is reasonable to write elective admission for varicose vein surgery.

History of presenting complaint

• This is a detailed description of the main symptom and should include the relevant systems enquiry.
• Try to put the important positives first, e.g. right-sided lower abdominal pain, sharp, worse with moving, and coughing, anorexia 24h.
• Include the relevant negatives, e.g. no vomiting, no PR bleeding.
• Be very clear about chronology of events.
• In a complicated history, or with multiple symptoms use headings, e.g. Current episodes, Previous operations for this problem Results of investigations.
• Summarize the results of investigations performed prior to admission systematically: bedside tests, blood tests, histology or cytology, X-rays, cross-sectional imaging, specialized tests.

Past medical history

• Ask about thyroid problems, TB, hypertension, rheumatic fever, epilepsy, asthma, diabetes, and previous surgery, specifically.
• List and date all previous operations.
• Ask about previous problems with an anaesthetic.
• Asking Have you ever had any medical problem, or been to hospital for anything? at the end often produces additional information.

Systematic enquiry

This is extremely important and often neglected. A genitourinary history is highly relevant in young females with pelvic pain. A good cardiovascular and respiratory systems enquiry will help avoid patients being cancelled because they have undiagnosed anaesthetic risks. Older patients may have pathology in other systems that may change management, e.g. the patient with prostatism should be warned about urinary retention.

• Cardiovascular. Chest pain, effort dyspnoea, orthopnoea, nocturnal dyspnoea, palpitations, swollen ankles, strokes, transient ischaemic attacks, claudication.
• Respiratory. Dyspnoea, cough, sputum, wheeze, haemoptysis.
• Gastrointestinal. Anorexia, change in appetite, weight loss (quantify how much, over how long).
• Genitourinary. Sexual activity, dyspareunia (pain on intercourse), abnormal discharge, last menstrual period.
• Neurological. 3 Fs: fits; faints; funny turns.

Social history

• At what time did they last eat or drink?
• Ask who will look after the patient. Do they need help to mobilize?
• Smoking and alcohol history.

Tips for case presentation

• Practice. Every case is a possible presentation to someone!
• Always set the scene properly. Start with name, age, occupation, and any key medical facts together with the main presenting complaint(s).
• Be chronological. Start at the beginning of any relevant prodrome or associated symptoms; they are likely to be an important part of the presenting history.
• Be concise with past medical history. Only expand on things that you really feel may be relevant either to the diagnosis or to management, e.g. risks of general anaesthesia.
• For systematic examination techniques see the relevant following pages.
• Always summarize the general appearance and vital signs first.
• Describe the most significant systemic findings first but be systematic inspection, palpation, percussion, and auscultation.
• Briefly summarize other systemic findings. Only expand on them if they may be directly relevant to the diagnosis or management.
• Finally, summarize and synthesize don't repeat. Try to group symptoms and signs together into clinical patterns and recognized scenarios.
• Finish with a proposed diagnosis or differential list and be prepared to discuss what diagnostic or further evaluation tests might be necessary.