Writing and presenting the history and physical examination
It is important that the medical record be kept short and simple. The following approach is one recommended by the authors. The detail of the history and examination and its record varies of course, depending on whether this is a first visit and on the complexity of the presenting problem. It is not necessary to ask every patient every question.
Record the name, sex, date of birth and address. Write down the date and time of the examination.
A short sentence identifies the major symptoms and their duration; it is often useful to quote the patient’s own words.
Don’t record every detail; rather, prepare short prose paragraphs telling the story of the illness in chronological order. Describe the characteristics of each symptom. Note why the patient presents at this time. Also, describe any past medical problems which are related to the current symptoms. Include the relevant positive and negative findings on the system review here. If there are many seemingly unrelated problems, summarise these in an introductory paragraph and present the history of each problem in separate paragraphs.
List current medications and doses and the indications for their use, if they are known, and any side-effects or known or measured therapeutic effects. For example, if the patient takes anti-hypertensive drugs ask whether blood pressure control has been satisfactory as far as the patient knows. Finally, record your impression of the reliability of the historian and, if the patient was unable to give the history, describe who was the source.
List in chronological order past medical or surgical problems (sometimes called inactive problems), past medication use, if relevant, and any history of allergy (particularly drug allergy) or of drug intolerance. Find out what the problem with the drug was. The patient may know the results of certain previous important investigations (e.g. ‘the scan showed I had clots in my lung’). A history of blood transfusions should be noted.
This may include recording the patient’s occupation, schooling, hobbies, marital status, family structure, personal support system, living conditions and recent travel. The number and sex of sexual partners may be relevant. Analgesic use, smoking, alcohol and other recreational drug use should also be described. Ask about ability to perform the activities of daily living (ADL). If a patient has a chronic illness, ask about the effect of this on his or life.
Under each of the major systems, list the relevant positives and negatives using brief statements. See Appendix II.
Ask yourself these questions when considering the differential diagnosis of a patient’s major symptoms.
1. What is the likely diagnosis based on the patient’s age, sex and background?
2. Are there other conditions that resemble the likely diagnosis but can present in the same way?
3. Is there a serious disorder, even if rare, that must not be missed?
4. Could the patient have a specific condition that often masquerades as (or mimics) other conditions (e.g. depression, drugs, diabetes mellitus, thyroid dysfunction, anaemia, malignancy, spinal cord disease, urinary infection, renal failure, alcoholism, syphilis, tuberculosis, HIV, infective endocarditis or connective tissue disease)?
5. Is the patient trying to really tell me that there is an emotional or psychological problem?
Using a sentence or two, summarise the most important findings and then give a provisional diagnosis (PD) and differential diagnosis (DD).
Remember Occam’s razor: choose the simplest hypothesis to explain observations. Also remember Sutton’s law: the famous bank robber said he robbed banks because ‘that’s where the money is’—i.e. consider a common diagnosis before resorting to a rare one to explain the symptoms and signs.
It is often useful to ask yourself if the patient’s problem is a diagnostic or management one (or both). For example, a patient with the new onset of dyspnoea presents a diagnostic problem—What is the cause of the breathlessness?; and a management problem—How should the condition be treated? The patient who presents with a worsening of previously diagnosed angina presents a management problem—How should the symptoms be treated?
List all the active problems that require management. Outline the diagnostic tests and therapy planned for each problem.
Sign your name and then print your name and position underneath.
Date (and time) each progress note in the record. The SOAP format can be useful (subjective, objective, assessment and plans).
Subjective data refer to what the patient tells you; list relevant current problems and note any new problems. Have the patient’s previous symptoms improved on the current treatment?
Objective data are physical or laboratory findings; relevant data for each active problem are summarised.
Assessment refers to the interpretation of any relevant findings for each problem.
Plans describe any interventions that will be started for each problem.
Many patient records are now kept in a computer file. Parts of this can be used to provide referral information for the patient to take to a specialist or if he or she is travelling. It is important that such files be kept up to date and especially that lists of medications that are no longer used are deleted from the current list before it is given to the patient.
In their formal examinations and less formally on the wards, students and resident medical officers will often be expected to present the history and physical examination of a patient to an examiner or senior colleague. This is excellent training for clinical practice, as the need to discuss patients with colleagues or specialists arises frequently in both hospital and non-hospital practice.
A successful case presentation is both succinct and relevant. The examiner is most interested in what the patient’s problems are now. One should aim to convey basic biographical information and an assessment of the patient’s presenting problem in the first few sentences. It is often helpful to frame the presentation of the case as a diagnostic or management problem, or both.
The information will have been obtained from the patient by taking the history as set out above. The examination of the patient should be performed with particular attention to the areas most likely to be abnormal. This information must then be assembled into a form that can easily be conveyed to others. The following is a suggested method.
1. Begin with a sentence that tells your colleague something about the patient and the clinical problem. For example, one might say ‘Mr Jones is a 72-year-old retired cabinet minister who presents with two hours of chest pain which is not typically ischaemic’. This gives an idea about the patient himself and indicates that the problem is likely to be a diagnostic one.
2. One should then go on to explain in what way the pain is atypical of ischaemia and whether it has features suggestive of any other diagnosis.
3. Once the presenting symptom or problem has been described, relevant past history should be discussed. In a patient with chest pain this would include any previous cardiac history or investigations, and a summary of the patient’s risk factors for ischaemic heart disease.
4. Present a list of the patient’s current medications.
5. Important previous health problems should be outlined briefly. This retired cabinet minister might also have a history of intermittent claudication and of chronic obstructive pulmonary disease. These facts will affect possible treatment for ischaemic heart disease, e.g. the use of beta-blockers.
6. Present the physical examination in two parts.
(a) Abnormal and important normal examination findings in the presenting system. In this patient’s case this would mean giving the pulse rate and blood pressure but not details of normal heart sounds. If there was a history of claudication, the examination of the peripheral pulses should be presented even if it is normal.
7. Offer the most likely diagnosis and the differential diagnosis.
8. Suggest a plan for investigation and treatment.
9. Much more detail will have been obtained in the assessment of the patient than should be presented routinely, but further details may be asked for by your colleague. These may include information about the patient’s living conditions and the availability of support from the family. This may determine how soon the patient can be sent home from hospital after treatment.
By the end of your presentation your colleague should know what you think is wrong with the patient and what you intend to do about it.