Example of a good medical history
There are 10 stages to a good medical history. Here goes.
Mr. MyHSN. 52 years. Accountant.
1. PC
Chest pain for 1 month.
2. HPC
Mr. MyHSN is a 52 year old accountant with hypercholesterolaemia, hypertension and polycythaemia rubra vera (PRV) who has been in relatively good health, until one month ago when he noticed chest tightness with exertion.
The patient recently decided to lose weight through exercising at the gym – and has began to run again. When running greater than six to seven blocks, the patient developed a tight feeling in his chest that subsided in approximately five minutes after he stopped running. He had a heavy gym session yesterday.
Initially, the feeling was mild, occurred only with the running and was associated with no other symptoms. It radiated into his jaw. At 5pm yesterday, while watching TV, he had the same pain, except this time it was of increased intensity (8/10), lasted 20 minutes, and was associated with shortness of breath and a brief period of sweating. His wife called an ambulance and he was admitted from A&E.
The patient is concerned that he may have the same problem that his father had.
3. PSH (surgical)
- Appendicectomy aged 12 years
- RTA aged 24 years; hospitalised for observation overnight.
Note. Its best to take this part of the history before the PMH, or you will forget.
4. PMH (medical)
- Polycythaemia rubra vera – diagnosed incidentally three years ago. Currently asymptomatic and treated every 6 months with phlebotomy
- Hypercholesterolaemia – diagnosed by screening two years ago
- Hypertension (essential) – diagnosed at work medical 10 years ago.
5. Medication
- Atorvastatin 40mg OD
- Amlodipine 5 mg OD
- Alternative medicine – none.
6. Allergies
He was told that he was allergic to penicillin as a child, but knows no further details.
7. Social history (SH)
- Lives with wife. One child at university
- Works as an accountant for a company that sells MRIs to healthcare systems
- Life stressors – concerned with child’s tuition finances
- Sexual history – one current partner (wife), does not use contraception as wife is postmenopausal
- Spiritual history – considers himself a spiritual person. Does not identify with a particular religion
- Tobacco – smoked 10 cigarettes a day until 12 years ago; still has the occasional cigar
- Alcohol – 10 units a week; taken 2x a week
- Recreational drugs – no history of use.
Note. Its not normally necessary to take a life stress, sexual or spiritual history with these symptoms. We are just showing you how to be complete.
8. Family history (FH)
- Mother – 79 years; hypertension, osteoarthritis
- Father – died aged 40 years, presumed due to an MI#
- 1 sibling – alive and well.
9. Systems review (SR)
- General – normal appetite and has no recent weight change or fatigue
- Skin – no rashes
- Eyes – vision is normal – wears glasses only for reading for the last year – last eye assessment was one year ago
- ENT – no changes in hearing, tinnitus, sore throat, nasal congestion
- Respiratory – no cough, sputum, haemoptysis or wheezing
- Gastrointestinal – gets occasional indigestion and heartburn; no nausea/vomiting, change in bowel habit, rectal bleeding or black stools
- Genitourinary – has noticed mild hesitancy when initiating urination – denies any discharge from his penis or testicular pain; no dysuria or frequency
- Musculoskeletal – denies any joint pain, redness, stiffness
- Neurological – denies syncope, seizures, weakness, numbness, tingling or changes in his memory
- Psychiatric – no feelings of depression or anxiety.
Note. If you are under time pressure, its best to ask relevant parts of the SR when doing the HPC.
10. ICE
- Ideas – thinks it may be a heart problem, or MSK as has been -over-exerting himself in the gym recently
- Concerns – that he is having a heart attack like his father. Feels guilty about cigar smoking
- Expectations – hopes that if it is a heart attack, he can have treatments that will stop another in the future.
Summary (how to present)
“Mr. MyHSN is a 52 year old accountant with a 1 month history of exertional chest pain that came on at rest 14 hours ago. He has a PMH of hypercholesterolaemia, hypertension and polycythaemia rubra vera. He is an occasional smoker.”
Diagnosis. “The most likely diagnosis is acute coronary syndrome (ACS), either unstable angina or a myocardial infarction. Differential diagnosis includes GORD and MSK pain. PE and infection is unlikely.”
