In writing up the history, be precise and well organized. The patient relates the history in his or her order; you need to reorganize the facts into the standard form discussed in Chapter 1 (i.e., chief complaint, history of present illness, etc.). Your skill in writing up the history will evolve with time as you gather more experience. Make sure that you organize the history in chronological order. Always record all the relevant data obtained. If data aren’t recorded, that data will be lost permanently. Be careful about using abbreviations; they may mean something different to others. As an example, PND often stands for paroxysmal nocturnal dyspnea; however, it is often used to mean postnasal drip (or discharge). Finally, be objective; the patient record is no place for editorial or judgmental comments. Your opinion should not be in evidence; just state the facts. For example, state, “alcohol on breath,” not “patient drunk.”

Interview of Mr. John Doe

Mr. John Doe, the patient, is lying comfortably in a two-bed room in St. Catherine’s Hospital. He is a white man, slightly obese, and in his mid-40s. Mr. Doe is watching television. The interviewer, wearing a white coat, enters the room.

(Interviewer smiles and extends hand for a firm handshake.)

Interviewer: Good morning, I’m Susan Smith, a second-year medical student. Are you Mr. John Doe?

(Pause; interviewer watches for response.)

Patient: Yes, I am.

(Extends hand to shake hand of Mr. Doe.)

Interviewer: Nice to meet you, Mr. Doe. I’ve been asked to interview and examine you today.

(Patient smiles, appearing friendly.)

Patient: Dr. James, my resident, told me you’d be coming to see me.

(Interviewer draws curtain around bed; pulls up a chair at the patient’s bedside and sits down; legs crossed, arms in lap.)

Interviewer: Would you mind if we turn off the TV?

(Patient turns off television.)

Patient: Not at all.

Interviewer: How are you today?

Patient: OK. No pain for the past 2 days.

Interviewer: Tell me about the problem that brought you to the hospital, Mr. Doe?¹

Patient: I’ve been having terrible chest pain for the past 6 months. . . .

(pause)

I guess I should start at the beginning. About 4 years ago, I started having this strange sensation in my chest. It wasn’t pain exactly. It was a dull, aching discomfort. I didn’t pay any attention to it. I guess I should have. . . . Well, anyway, I was able to go to work, play tennis, and have fun. Occasionally when I had an argument at work, I would get this sensation.

(looking sad)

My wife never knew anything about it. I never told her. No one knew. I didn’t want to upset them. Then all of a sudden on July 15, 2012, it happened.

(silence)

Interviewer: It happened?²

Patient: Yeah. I had my first heart attack.³

I was playing tennis when I got this awful pain. I never had anything like that before. I was just getting ready to serve when this pain hit me. All I could do was lie down on the court. My partner ran over to me, and all I remember was that pain. I woke up in Kings Hospital.

(pause)

They told me I lost consciousness and was taken to the hospital by ambulance. I remember that when I came to in the hospital, I still had the pain. I was there for 2 weeks.

Interviewer: How did you feel when you left the hospital?

Patient: I really felt fine. No more chest pain. My doctor there had given me some pills and said I would be fine.⁴

Interviewer: Then what happened?⁵

Patient: I went back to work after about 3 weeks. I really felt great!

(smiles)

Interviewer: What type of work do you do?

Patient: I’m a lawyer.

Interviewer: You mentioned that this was your first heart attack. Have you had others?

Patient: Unfortunately. . . .

(looking down)

Yes.

Interviewer: Tell me about it.⁶

(leaning forward⁷)

Patient: Six months later, I had my second attack.

(pause)

Interviewer: What were you doing?

Patient: Playing tennis.

(silence)

This time I don’t remember anything . . . not even the pain. I remember being on the court and waking up in the intensive care unit of Kings Hospital. They said I had a massive heart attack and had some irregularity of my pulse that made me faint. But I left the hospital in 3 weeks feeling much better. I went back to work after 3 weeks at home.

Interviewer: Did you have any tests while you were in the hospital?

Patient: No. . . .

(pause, hand over mouth)

The doctor just gave me some pills to strengthen my heart and for the irregularity.

(silence for 10 seconds)

Interviewer: Your silence makes me think that you want to tell me something.⁸

Patient: I should have listened to him.

(pause, shaking head)

Interviewer: To whom?

Patient: My doctor suggested after my first heart attack that I should have cardiac catheterization. I told him that I was fine, I didn’t need it. Even after my second attack, I didn’t listen to him.

(pause)

I hope it’s not too late.

Interviewer: Too late?

Patient: Yeah. That’s why I’m here. I’m going to have the cardiac catheterization tomorrow. Emily finally convinced me to have it.

(pause)

I’ve really not been able to do anything for the past 6 months.

(pause, looking down)

I had to give up my work at the office. Sure, they still call me for advice, but it’s not the same.

(pause, almost tearful)

The commuting by car just got to me.

(pause)

My son and his friends yelling around the house.

(longer pause)

I just can’t take it anymore.

Interviewer: What did your doctor tell you about the test?⁹

Patient: The doctor told me if I have some blockage, he’ll operate or fix it with a balloon or a type of Roto-Rooter. Will I be normal again?

(pause)

Interviewer: After the study, your doctor will be in the best position to answer that question.¹⁰

(pause)

Tell me about the pain you’ve been having.

Patient: It seems I have the pain all the time. I can hardly walk up the stairs at home without getting the pain.

Interviewer: What’s the pain like now?

Patient: It’s an awful tightness, like a vise. . . .

(closes fist over chest¹¹)

Right here.

Interviewer: When you get the pain, do you feel it anywhere else?

Patient: Yeah. It goes straight to my back and my left arm. The arm feels so heavy.

Interviewer: Are there any other times when you get the pain?

Patient: It seems I get it with the slightest effort or emotion.

Interviewer: Do you get the pain during sexual intercourse?

Patient: I had to stop even that 6 months ago. I’d get the pain just when I’m about to come . . . and . . . and . . . I’d have to stop.

Interviewer: Have you had any difficulty breathing?

Patient: When I get the pain, I get short of breath.

Interviewer: Do you ever get short of breath without the pain?

Patient: I find I just can’t walk far any more without getting winded.

Interviewer: How many level blocks can you walk now without getting short of breath?

Patient: About one block.

Interviewer: How much could you walk 6 months ago?

Patient: I guess about two to three blocks.

Interviewer: Since your heart attack, have you had any skipped beats or fluttering of your heart?

Patient: No, never.

Interviewer: Has anyone ever told you that your cholesterol or fats in your blood were high?¹²

Patient: No.

Interviewer: Have you ever smoked?

Patient: I stopped after my first heart attack.

Interviewer: That’s great that you stopped smoking. How much did you smoke?

Patient: About two packs a day.

Interviewer: For how long?

Patient: Oh . . . since I was about 18.

Interviewer: May I ask your age?¹³

Patient: I’m 42.

Interviewer: Have you ever had high blood pressure?

Patient: Yep. My doctor gave me some medications for it, but . . . but . . . I never refilled the pills after they ran out . . . I felt fine.

Interviewer: Do you know how high your pressure was?¹⁴

Patient: Not really.

Interviewer: Do you have diabetes?

Patient: Thank goodness, I don’t. My father does, though. He’s been pretty sick lately. He’s got some sort of a problem with his eyes. The doctor said that it’s from his diabetes. He’s going to see a specialist in a couple of weeks. He’s had a lot of problems. He broke his hip a few years ago when he was walking our dog. Some big guy came pulling a cart out of the supermarket and knocked my father over. He was hospitalized for several weeks because he really couldn’t take care of himself. His hip is fine now. He would. . . .

Interviewer:(interrupting) I’m glad his hip is well healed. Is there anyone else in your family who has diabetes?¹⁵

Patient: No.

Interviewer: Anyone else in your family who’s had a heart attack?

Patient: I think my mother’s father died of a heart attack.

Interviewer: How old was he?

Patient: About 75.

Interviewer: What about your mother?¹⁶

Patient: She died when she was age 64 . . . right after my first heart attack. She had stomach cancer. She really suffered. . . . I guess it’s a blessing.

Interviewer: Do you have any brothers or sisters?

Patient: My sister is 37 and she’s fine.

Interviewer: Any other siblings?

Patient: My brother is 45. He had a heart attack when he was 40.¹⁷

Interviewer: Do you have any children?

Patient: One boy who’s 15.

Interviewer: How’s your son’s health?

Patient: No problem, except he’s a little overweight.

Interviewer: Are you married?¹⁸

Patient: To a great gal. Emily’s the one who convinced me to have the test.¹⁹

Interviewer: Does anyone in your family have high blood pressure?

Patient: No.

Interviewer: Asthma?

Patient: No.

Interviewer: Tuberculosis?

Patient: No.

Interviewer: Birth defects or congenital diseases?

Patient: Not that I know of.

Interviewer: Have you ever been hospitalized here at St. Catherine’s Hospital?

Patient: No.²⁰

Interviewer: Have you ever been hospitalized at any time other than for your heart attacks?

Patient: I had my appendix taken out when I was 15.

Interviewer: Do you remember the surgeon’s name and the hospital?

Patient: I think it was a Dr. Meyers at Booth Memorial Hospital. We were living in Rochester.

Interviewer: Any other operations?

Patient: No.

Interviewer: Have you ever been hospitalized for any other reason?²¹

Patient: No, what do you mean?

Interviewer: Just a routine question. Do you have any allergies?

Patient: No.

Interviewer: How was your health as a child?

Patient: I guess OK. I had the usual sore throats and ear aches that most kids get.

Interviewer: Did anyone ever tell you that you had rheumatic fever?²²

Patient: No.

Interviewer: Did you have any of these illnesses?²³ Chickenpox? Measles? Diptheria? Polio? Mumps? Whooping cough?

(Patient shakes head “no.”)

Do you take any medications?

Patient: Just atenolol and isosorbide dinitrate.

Interviewer: Do you know the dosages?

Patient: I take 50 mg of atenolol once daily and 10 mg of isosorbide dinitrate 4 times a day.

Interviewer: Do you think the medications help you?

Patient: I guess so. I think I feel better with them.

Interviewer: Any other medications?

(pause)

Patient: Nitroglycerin . . . when I get the pain.

Interviewer: How long does the nitroglycerin take to work?

Patient: Real quickly.

Interviewer: How long is that?

Patient: About 4 to 5 minutes.

Interviewer: Do you take any other medications?

(pause)

Over-the-counter medicine? Herbal medicines? Anything else?

Patient:(thinks for a moment) I take Chlor-Trimeton when I get a cold . . . but that’s about it.

Interviewer: Have you ever had any other health problems?

Patient: No.

Interviewer: Any problems with your liver? Kidneys? Stomach? Lungs?²⁴

(Patient shakes head “no.”)

How’s your appetite?

Patient: Pretty good. I haven’t been real hungry lately.

Interviewer: Starting with breakfast yesterday, what did you eat?

Patient: Toast, coffee, and juice for breakfast. . . .

(pause)

A ham sandwich with a Diet Coke for lunch. . . .

(pause)

Oh, yeah, blueberry pie for dessert. . . .

(pause)

And . . . uh . . . steak with a baked potato and salad for dinner.

Interviewer: Any snacks between meals?

Patient: I had a cupcake with milk before I went to bed.

Interviewer: Do you eat fish?

Patient: Sometimes.

Interviewer: How often?²⁵

Patient: Maybe. . . .

(pause)

Once every 2 weeks. I enjoy shrimp, but I know it’s not good for me.²⁶

Interviewer: Have you had any weight change recently?

Patient: I lost about 10 pounds in the past 3 months. . . .

(pause)

But I wanted to. . . .

Interviewer: Were you on a diet?

Patient: No, not exactly. . . . I just haven’t been too hungry lately.

Interviewer: How well do you sleep?²⁷

Patient: Like a baby. . . .

(pause)

Although I’ve been getting up pretty early recently.

Interviewer: Mmmm?

Patient: Yeah, recently I go right to sleep, but seem to get up about 3 in the morning and can’t go back to sleep. . . .

(pause)

I guess I’ve got a lot on my mind. . . .

(pause, looking down, hand to mouth)

Interviewer: You seem depressed.²⁸

(Patient pauses)

Patient: I guess I am. . . . What’s going to happen to me? I really want to live. . . .

(beginning to cry)

I’ve been so stupid. . . .

(pause)

My kid’s only 15. He’s a great kid. . . . He needs me. . . . What’s the test gonna show? I hope I can have the surgery or the balloon to get relief from this pain.²⁹

(Interviewer is silent, handing a box of tissues to the patient.)³⁰

(Patient is sobbing, trying to control his emotions.)

I’m sorry. . . . I can’t help it. . . .

(wiping his tears)

I guess we’ll have to wait till tomorrow.

Interviewer: I just have a few more questions for you. Do you drink alcohol?

(Patient shakes his head “no.”)

Patient: Just socially . . . one drink . . . maybe after work, sometimes.

Interviewer: Do you ever feel that you have a need for a drink as the day goes on?

Patient: Yeah, I sure do!

Interviewer: Have you ever felt the need to cut down on your drinking?

Patient: No.

Interviewer: Have people annoyed you by criticizing your drinking?

Patient: Never . . . but my wife doesn’t like me drinking.

Interviewer: Have you ever felt bad or guilty about your drinking?

Patient: Yeah. . . . Once about 10 years ago my friend’s father made some wine. We got really drunk . . . it was terrible . . . but never again!

Interviewer: Do you drink in the morning?

Patient: Never.

Interviewer: Do you ever drive while intoxicated?

Patient: No! That’s suicide.

Interviewer: Do you drink coffee or tea?

Patient: About three cups of coffee a day at work. I have tea only when I’m sick with a cold.

Interviewer: Have you ever used recreational drugs?

Patient: I’ve tried pot a couple of times . . . never did anything to me. . . . Nothing else.

Interviewer: What’s your usual day like?³¹

Patient: Before I stopped working at the office, I got up about 5:30, dressed, and was at my desk in the office by 7:30. I usually left the office about 7 and got home by 8:15. We’d have dinner, and I’d be in bed by 11:30, after the news.

Interviewer: Sounds like you have a pretty busy day.

Patient: Yeah. I enjoy my work . . . or at least I used to.

Interviewer: How long have you been working with your present office?

Patient: I started right after law school. I guess I’ve been there . . . about . . . 17 years. I’m one of the senior partners.

(pause)

I was just promoted. . . . A lot of good that will do now.

Interviewer: Congratulations on your promotion! I now have several questions to ask you. You can answer just “yes” or “no” to each.³²

(pause)

Have you had any recent fevers?

Patient: No.

Interviewer: Chills?

Patient: No.

Interviewer: Sweats?

Patient: No.

Interviewer: Rashes?

Patient: No.

Interviewer: Changes in your hair or nails?

Patient: No.

Interviewer: Headaches?

Patient: Rarely, about once every 2 to 3 months.

Interviewer: For how long have you been having headaches?

Patient: Years. . . . I guess about 20 to 25 years.

Interviewer: Can you describe them to me?

Patient: That’s hard. They’re right here.

(pointing to the center of his forehead)

They last about 1 to 2 hours.

Interviewer: What relieves them?

Patient: Usually aspirin.

Interviewer: Have you noticed a change in the pattern or severity of your headaches?

Patient: No.

Interviewer: Have you had any head injuries?

Patient: Never.

Interviewer: Have you ever fainted?

Patient: No.

Interviewer: Do you have any problems with. . . .³³

(The interviewer completes the review of systems.)

Is there anything else you would like to tell me that I haven’t asked about?

Patient: No . . . you’ve certainly been very thorough.

Interviewer: Let me summarize your history briefly to make sure I have the details correct before I proceed with your physical examination. This is your first time here at St. Catherine’s Hospital. You had your first heart attack on July 15, 2012, while playing tennis. You were hospitalized in Kings Hospital for 2 weeks. Your second heart attack was 6 months later. You were again hospitalized in Kings Hospital. Your medications since then have been atenolol, 50 mg once daily, and isosorbide dinitrate, 10 mg four times a day. Because of a worsening of your chest pain and an increase in your shortness of breath in the past 6 months, you’re now being admitted for cardiac catheterization. Is that correct, Mr. Doe?

Patient: Exactly!

Interviewer: Do you have any questions for me before I begin your physical examination?

Patient: No . . . I can’t think of any.

(The interviewer stands up, sets up the equipment on the night table, and goes to the sink to wash her hands. The physical examination then commences.)

(Interviewer concludes the physical examination.)

Interviewer: It’s good you came in today; we are going to do everything possible to help you feel better.

Patient: Well . . . what do you think? Will I make it?

(Interviewer opens curtain around patient’s bed)

Interviewer: I’m now going to meet with my preceptor. Afterward, we’ll be back to discuss your medical condition.³⁴

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1. The Focused History and Physical Examination
2. The Head and Neck
3. The Pediatric Patient
4. The Musculoskeletal System

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