BASIC GUIDE FOR CREATING A CLINICAL HISTORY.

FROM THE DATA

FROM PATIENT IDENTITY TO THE CREATION OF THE HISTORY OF THE
CURRENT ILLNESS.

Introduction

This is the first in a series of works aimed at students pursuing a degree in

medicine in Cuba, from the IV to VI semester. The authors' objective is to provide a
didactic instrument that allows for quick guidance and efficient practice in the
creation of Clinical Histories. The GUIDE is mainly instructive and utilizes the
synthesis, mnemonic resources, and concept maps for easy understanding. Not
aims to replace the use of basic texts and encyclopedic works of semiology
where the student has the detailed and organized information for their correct
Preparation, ITS MAIN OBJECTIVE IS TO HELP WITH STUDYING IN THE DAYS LEADING UP
AT A FINAL SEMIOLOGY EXAM, when there is not enough time to re-read thousands
of pages.

This GUIDE will be a useful support for those who have already completed the learning stage.
and they face the final evaluation, or better yet, for those who decide to execute with quality the
clinical practice, with its scientific methods and procedures.

The Medical History for a beginner:

Why is a properly crafted Medical History important?

• It is the basic document of healthcare.

• Methodological guide to comprehensively reflect health problems.
• Identify not only the circumstances that led to seeking medical consultation, but also
all your needs.
• Basis for the planning, execution and control in each case, of the actions
intended for the promotion, recovery, and rehabilitation of health.

When the patient arrives for the first time at the consultation, a questioning and an examination are required.
meticulous physicist, although there are some aspects that should never be forgotten in which
we will emphasize. Sometimes we try to make the semiography so perfect that we overlook details
fundamentals, very necessary for an accurate diagnosis.

General Data of the Medical History.

1) Personal identity data:

First and Last Name.

b) Age: A diagnostic value etiological factor. They are common in childhood: the
gastrointestinal disorders, often due to poor eating habits. In puberty
disorders related to the development of sexual functions are found.
mature age weighs the struggle for life and the full enjoyment of vital functions. Here it
nervous disorders, venereal diseases, and metabolic diseases are observed. Cancer is
more frequent after the age of 40, although it can appear at an early age
of life. In old age we find, above all, atherosclerosis and its complications, the
pulmonary emphysema and prostatic hypertrophy, among others.

c) Sex: Aside from the diseases that affect the genital apparatus, naturally different
in both sexes, this fact is interesting due to the semiological value it attains in some
Cases. Indeed, sex seems to influence in some way the appearance of certain
diseases that the statistics present with a clear predominance in one or the other. Thus
we can point out the highest frequency of exophthalmic goiter, hysteria, chorea, and headache
hemicrania, obesity, and gallstones in women. In contrast, in men they are much more
more common certain nutritional diseases (diabetes and gout), pernicious anemia,
aortic injuries, etc.
d) Skin color: The influence of ethnic factors on the etiology of diseases
justify that it is taken into account in the medical history, where they sometimes acquire certain
semiological value; the vast majority of breeds have a genetic predisposition to
certain diseases. Although one should be cautious when inferring a possible diagnosis due to the
evident mixing of races in the world.

e) Occupation: It acquires significant importance as an etiological factor in many

occupational diseases. Naturally, in those cases, its diagnostic value is great,
often decisive. Most of the time the stress that the patient suffers in their
work medium and/or constant exposure to hazardous factors (toxic-
infectious) are the source of various diseases, in addition to the fact that each profession has
a typical condition that requires a special position from people that
triggers specific ailments, e.g., varicose veins in the lower limbs.
those who work standing up (dentists, salespeople) and obesity in professions
sedentary. The frequency with which they suffer from myocardial infarction must be cited.
people subjected to great emotional stress, among them, doctors.

f) Marital status: It offers a diagnostic interest as numerous infectious diseases

contagious depend on the continuous contact between the populations of both sexes,
especially in women, whose genital conditions depend to a high percentage on
sexual relationships.

g) Private address

h) Blood type

2) Reason for Consultation (R.C)

It refers to the brief notation of the symptoms that lead the patient to seek consultation, having to
write your own words for this. It should consist of one or several words or one or two
The reason for the consultation is one, when we sometimes find ourselves in front of a difficult patient.
that begins to mention conditions, it is necessary to define which one concerned him the most and
for which he/she attended the consultation.

Examples of common consultation reasons frequently presented in our field:

Headache.
Diarrhea.
Chest pain.
Blood vomit.
Fever.
Diarrhea with blood.
Cramps.

The diagnosis or interpretation of symptoms should not be included in the reason for admission.
another doctor, and terms like 'duodenal ulcer', 'gallbladder stones' should be avoided
“hipertensión arterial”, “diabetes”, “hematemesis”, “melena”.

In our country, medical culture has become much richer, so we can find ourselves.
in the situation where the patient expresses themselves in medical terms, in that case it will be written the
consultation reason in quotes.

Example:

Headache
Angina pectoris
Hypoglycemia
Hyperthermia
Dysentery
 Heart failure
Tachycardia
Dyspnea

3) HEA - History of Current Illness

It represents a compilation of the complaints that the patient brings to the doctor and expands on the data of
reason for admission. This part requires more skill in taking the history. A judicious
The interrogation will give us the details of the patient's complaints. Only a few patients are so
good observers who can give us the complete history of their current illness without
need for a directed interrogation. When we encounter a patient who gives us a
good and detailed story, we usually suspect that the patient has read about their
symptoms or has already consulted other doctors, who have asked them questions. Many
patients tend to deviate from the history of their current illness, and the examiner must, therefore,
the interrogation, to guide it through the logical development of his story. This can be done with
more ease if the patient is taken to a chronological recount of their symptoms.

The history of the current illness is divided into two parts for better organization.
while being interrogated:

Chronopathogram: It collects the patient's main ailments, time of

evolution of the same and regular treatment for their control.

History of the current disease itself: All will be developed

semiological characteristics of the symptom referred in the M.C. In the case of pain, or another
symptom or sign where applicable, one or several elements of the
next mnemonic resource:

METHODS TO IDENTIFY SYMPTOMS

Classic questions in increasing order:
a) How do you feel?
b) In which part of the body do you feel the discomfort and where does it 'run' or radiate to? (very
necessary in case of pain.
c) When did the symptom start?
d) How has it evolved until today?
e) With what is modified (increasing or decreasing intensity / varying the character):
it can be with foods, positions, medications, etc.
f) Do other symptoms or manifestations associate with it?

MNEMONIC RESOURCES TO CHARACTERIZE SYMPTOMS

If pain: ALICIA FREDUSAH

A:Appearance. Character:
Location. Colic: (progressive increase to maximum
I: Intensity. intensity, then decreases). Burning (Urge).
C:Character or quantity * Deaf: (maintained, slight, imprecise and uncomfortable).
I: Irradiation Oppressive (restrictive). Pulsatile (associated with the pulse).
Relief Neuralgic: (runs through a nerve). Stabbing (like
FRE:Frequency (Rhythm) stab). Dazzling (like a lightning bolt, whip or
Duration electric shock). Boring: (intense, like a
Accompanying Symptoms drill).
H: Schedule

Yes, vomiting:
• food.
• biliary: yellowish.
 • porridge: dark, with partially digested food.
• fecaloids.
• hemorrhagic (hematemesis: originating from the stomach and expelled with retching)
differentiate from hemoptysis (elimination by expectoration or cough).

Examples

Below we show some examples of how a HEA is written:

Case 1:

Chest pain.

H.E.A: Male patient, 56 years old, who reports suffering from Type 2 Diabetes Mellitus
1 for 30 years, currently treated with diet and 40 units of slow insulin daily; suffers from
in addition to high blood pressure for 10 years, currently treated with diet,
Chlorothalidone (25mg) 1 tablet per day, Captopril (25mg) 1 tablet every 8 hours and Verapamil (80mg)
1 tablet 3 times a day. Visit today for a consultation due to chest pain that appeared.
approximately 30 minutes ago, located in the precordial area, of moderate intensity
a severe, oppressive character, radiating to the epigastrium and the left arm. It is a pain
pain that has not been relieved by anything so far. It is accompanied by vomiting and
cold and sticky sweating.

Case 2:

M.C: 'Headache'.

H.E.A: Female patient, 35 years old, with apparent health history, who
He/She comes today for a consultation due to 'headache'. It started 2 days ago halfway.
right side of the head, of severe intensity, pulsating character and radiates towards the eye and cheek
right. The pain decreases with rest in a dark room, the administration of
Amicodex ¼ of a tablet every 8 hours and cold compresses in the region of pain. It is the same.
occurs once a month, in the days leading up to the start of menstruation, lasts from 3 to 4 days,
without preference for a specific schedule and accompanied by general malaise, lack of appetite and
nausea.

Case 3

M.C: Fever

H.E.A: Male patient, 20 years old, with a history of bronchial asthma

severe persistent for 15 years, currently treated with Ketotifen (1mg) 2 times
the day and Salbutamol in spray 4 times a day depending on the symptoms. The patient
presents around 4 exacerbations per week for which he has to go to the hospital,
has been hospitalized at least 3 times in the year due to crises and exacerbations occur
mainly due to changes in weather, exposure to allergens, and some situations of
stress. He comes to the consultation today because he has had a fever of 39°C for 4 days, which began in
the afternoon schedule lasts all night and disappears in the morning, which is relieved with
dipyrone (300mg) 2 tablets every 8 hours and lukewarm water baths, accompanied by chills,
sweating, fatigue, loss of appetite, and nausea.
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Bibliographic references:

1. Llanio Navarro, Raimundo; Perdomo González, Gabriel. Clinical Propedeutics and

Medical Semiotics. Medical Sciences Publishing, 2005. Volume I and II.
Roca Goderich, Dr. Reinaldo. Topics in Internal Medicine. Havana. Editorial
Medical Sciences, 4th Edition, 2002. Volumes I, II, and III.
3. The Merck Manual of Diagnosis and Therapy. Tenth Spanish Edition. Madrid. 1999.
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Authors:

Marco J. Albert Cabrera (1)

Suiberto Hechavarría Toledo (2)
Yaima C. Pino Peña (3)
Aileén Gómez Hernández (4)
Arián Luís Rodríguez (4)
Arturo E. Rodríguez González (4)

Master in Sciences. Specialist of First and Second Degrees in Internal Medicine.

Specialist in Second Degree of Comprehensive General Medicine. Assistant Professor.
Higher Institute of Medical Sciences of Havana.
Master’s in Sciences. First Degree Specialist in Internal Medicine. Professor
Assistant. Higher Institute of Medical Sciences of Havana.
First Degree Specialist in Comprehensive General Medicine.
6th year medical students. Vedado University Polyclinic.