Itroduction to Internal Medicine

Introduction
The medical history is the foundation of internal medicine. The answer to the patient’s problem is in the history 90% of the time! The other 10% of the time, you will need to use investigations to help you figure the answer out.
Identification
Start your presentation with the patient’s name, age, sex, home and referral status. Fore example: Luke Smart, 32 year old male, self referral to Bugando Medical Centre.
Chief Complaint (CC)
This is the main reason the patient came to the hospital. Ask the patient, “Why did you come to the hospital?” It is normally, one complaint, but can contain up to two or even three main complaints. State the duration of the complaint. For example: disturbance in breathing for two weeks.
History of Present Illness (HPI)
This should be a story about how the symptoms developed. Use the patient’s own words as much as possible. Avoid medical terminology (like the word “angina”) unless the patient actually uses that word. Usually a patient will say “chest pain” instead of “angina.” Begin with the earliest symptoms related to the chief complaint and proceed chronologically. For example: “The patient described chest pain when walking up a hill four weeks ago. This resolved with rest and recurred with activity. Eventually the chest pain subsided and the patient began to experience shortness of breath when walking short distances. One week ago, the patient began to notice that they were short of breath when lying flat and began having swelling in his legs.
Review of Other Systems (ROS)
Review the systems that are not involved in the chief complaint. The system that is involved in the chief complaint should be reviewed within the HPI. Usually the ROS is done from head to toe (neurological, cardiovascular, pulmonary, gastroenterology, renal, genitourinary, and musculoskeletal). Review every system every time you take a history, but when you present the patient, only mention the ones that are important negatives and positives related to the chief complaint. For example, if the patient has abdominal pain, then the gastroenterology system will be reviewed in the HPI, and the cardiovascular, renal, and genitourinary systems ought to be specifically mentioned in the ROS. If you do not know which systems are relevant to the HPI, it is always better to include more information than less.
Past Medical/Surgical History (PMSHx)
This includes past admissions, chronic medical problems, medications, allergies, immunizations, prior surgeries, prior blood transfusions, and for women gynecological history. Any part of the PMHx related to the CC should also be mentioned in the HPI. For example, if the patient presents with chest pain that started one month ago and was admitted two weeks ago for this complaint, then it should be included in the HPI. One way to figure out if they have any chronic medical problems is to ask if they have ever gone to the clinic or if they are on any medication. For some past medical problems it is important to include more than just a diagnosis. For example, if the patient has IDS, then you want to include their baseline CD4 count, whether they are on ART, and if so how long. Forthe allergy section, ask specifically what kind of reaction they had. If they don’t remember what kind of medicine they had an allergy to, you can always try to figure out what medication it is by asking them why they were taking it. You can also ask if it was a pill or an intravenous medication. For women remember to include the last menstrual period.
Family/Social History (FSHx)
A complete social history includes marital status, number of children, the location of their home (region/village), type of home, number of children, occupation, level of education, alcohol use, tobacco use, illicit drug use, and sexual history.
Tobacco history should include how many cigarettes they smoke per day and how long they have smoked. This is reported in pack years. Pack years are equal to the number of packs per day multiplied by the number of years they smoked. If the patient smoked one pack per day for ten years, then they have a ten pack-year history of smoking. If they smoked 5 cigarettes per day for four years that is equal to ¼ pack x 4 years which equals one pack-year. Also report the type of cigarettes used. The alcohol history should include the type of alcohol, the amount per sitting, how many times per week, and the total number of years that the patient drank this much.
The sexual history should include the number of current partners (or the number of partners in the past month), the total number of past partners in the patient’s life, any history of sexually transmitted infections, the age at first intercourse, and whether the patient uses protection when having sex.
The family history should include any inheritable diseases such as diabetes mellitus, sickle cell disease, and heart disease, as well as anything related to diseases that look like the chief complaint.