By Mille Vissing, MD, Mie Pilegaard Bjarnesen, BCs. med. and Mia Wangsmo Steffenssen, MD
Documentation of medical history (anamnesis)
Documentation of patient history should or can include the following:
Chief complaint: The patient’s age, sex and primary complaint concerning the hospitalization.
Allergies: Known allergies including but not limited to iodine, bandages, antibiotics, soy, and latex. Note the physical response to the allergen (e.g. respiratory distress or skin eruption). It can be useful to note if the patient has been given penicillin or morphine before without experiencing allergic reactions.
Family history: Relevant family history of disease and known hereditary diseases including incidences of cancer.
Past Medical/Surgical History: Medical history requiring clinical treatment and surgical procedures is organized in reverse chronological order, with the most recent admissions first. The following structure should be applied:
“(month of event), year, clinic/hospital: Medical issue and lateralization, treatment and any potential sequelae.”
Below the list, current medical issues and chronic illnesses, where the exact dates of events are not known such as diabetes, coagulopathies or high blood pressure can be listed, but it is preferred to get all the details if possible. Any known complications with anesthesia such as nausea and vomiting are valuable information for the anesthesiologist and should also be noted.
Current concern: Short description of the debut of symptoms; localization, duration, development, and complaints concerning the patients current medical or surgical problem. Note other relevant information such as findings on previous scans or other paraclinical investigations that relate to the issue. Issues concerning the patient’s general condition that might influence the postoperative patient care is valuable information and should be noted. Lastly symptoms that link to malignant disease should also be noted including drowsiness, weight loss, and night sweats. In case of Massive weight loss (MWL) patients note method of weight loss i.e. bariatric surgery or change in lifestyle, reduction in BMI point (note highest and lowest BMI score), total weight loss (note highest and current weight) and for how long the weight loss has been stable.
Review of Organ Systems
This review of the different organ systems is solely based on the patient’s subjective concerns. Some points are likely to reappear in the subsequent physical examination which conversely is limited to your observations.
Central nervous system: Headache, loss of consciousness, dizziness and vertigo, difficulty speaking, memory loss, and drowsiness. Note symptoms related to cranial nerves such as: Impaired vision (amaurosis, diplopia), facial numbness, deafness, dysphagia, limb motor or sensory symptoms, and loss of coordination.
Psychiatric system: Anxiety, depression, body dysmorphic disorders.
Cardiopulmonary system: Chest pain, dyspnea, ankle swelling, and heart palpitations. Cough, hemoptysis, epistaxis, wheezing, and respiratory related chest pain.
Gastrointestinal system: Change in weight, dysphagia, abdominal pain, vomiting, and change in bowel habits.
Genitourinary system: Dysuria, urethral discharge, incontinence, disturbances in menstruation and sexual activity.
Endocrine system: Weight loss, polydipsia, polyuria, increased appetite, and irritability.
Musculoskeletal system: Bone, joint or muscular pain and any loss of function including claudication.
Skin: Rashes, use of sunscreen creams when exposed to the sun, noted wounds or changes in moles.