2. Marco de Referencia
2.2. Marco Histórico Situacional
Information in this section is intended for staff new to HIV surveillance or without clinical backgrounds.
Medical records and diagnostic reports provide the organization, communication, and coordination needed to ensure good patient care. The foundation of the medical record is the physician’s examination, and the record of information from the exam becomes the body of the medical record.
A medical examination, often referred to as the history and physical, or H&P, comprises four basic sections:
• Medical history
• Physical examination
• Diagnostic impression
• Treatment plan
Most physicians follow a general pattern or structure during the exam, and the information in the medical record follows that pattern. In hospitals, many medical exams follow a similar, if sometimes abbreviated, format.
To understand the medical record, you need to know the process and procedures used in the exam.
M E D I C A L H I S T O R Y
The starting point of the medical exam is customarily the “chief complaint” that brought the patient to the physician’s office or the hospital. Ordinarily, this complaint and its duration are recorded exactly as the patient expresses them.
The physician then asks about the present illness and encourages a full description of all symptoms and the circumstances under which they become more acute, subside, or persist unchanged.
p.i. [present Illness]: Three weeks ago, this 40-year-old, married WF [white female] had a cold with
associated mild cough and To [temperature] that lasted 2 days. 100.1o taken orally by pt. [patient]. At this
time, there was loss of appetite, and food intake was decreased. After the cough and temp. elev. subsided,
pt. noted increasing weakness and general malaise. Exercise, which was tolerated well before URI [upper
respiratory infection], now tires her considerably.
One week ago, she noticed excessive thirst and a feeling of nausea. She had nausea and vomiting yesterday (×2) of clear, yellow liquid. Stools soft but no diarrhea. Increased frequency of urination. Denies any difficulty or burning with urination. There has been a 25–30-pound unintentional wt. [weight] loss during the past year.
After the immediate health problem is discussed thoroughly, the physician broadens the field of inquiry to view the patient in relation to a full range of environmental and hereditary factors.
Medication
The physician inquires about any drugs being taken. He asks the patient to be as explicit as possible about the names, doses, and effect of current medications.
Pt. took 2 ASA [aspirin] BID [2 times daily] while To increased.
Allergies
The physician inquires in detail about known sensitivity to food, pollen, or medication.
NKA [no known allergies]. Past Medical History (PMH)
Next, the physician obtains extensive information about the patient’s past medical history: diseases of childhood, serious illnesses, injuries, and surgical procedures. If the patient is a woman, the physician asks about pregnancies, both completed and interrupted.
P.H. [past history]: UCHD [usual childhood diseases]. Pneumonia, age 31. Appendectomy, age 24 (8/75),
Bigtown Memorial Hospital, C.J. Green, M.D. Grav IV [four pregnancies], Para III [has had three children],
Ab. I at 2 mo. [abortion, one in second month].
Social History
The patient’s personal habits with respect to food; smoking; consumption of coffee, tea, and alcohol; hours of sleep; and self-medication are recorded. To obtain a total personal profile of the patient, the physician seeks information about social history: education, geographic sites of past residence, marital history, past and present occupations, and place of work.
S.H. [social history]: Born in Peru, Indiana, 1951. High school education. Congenial family life. Habits;
smokes 1½ pks/day. Denies use of alcohol and drugs O.H. [occupational history]: Pt. has been a housewife
Family History
The physician inquires about family history, including information about parents, grandparents, siblings, spouse, and children. Familial diseases can provide major clues, as can causes family members’ causes of death. The physician might enter family composition in the chart as a diagram.
F.H. [family history]: Mother A&W [alive and well] age 67. Father died age 55 of “heart trouble.” An aunt
has diabetes. Fourth of 5 sibs [siblings]—two and three. Mother of three children, one, two.
At this point in the interview, the physician might have arrived at a hypothetical diagnosis of the illness, which will be more precisely differentiated on the basis of the findings of the physical examin, subsequent laboratory testing, and radiographs.
Review of Systems
The medical history continues with a review of present and past disorders through the full range of organs or systems: head, eyes, ears, nose, throat; oral, respiratory, cardiovascular, gastrointestinal, genitourinary, menstrual, metabolic, neuromuscular, dermatologic, lymphatic, and neuropsychiatric.
R.O.S. [review of systems]
HEENT [head, ears, eyes, nose, throat]
General: 30-lb. decrease × 1 yr (nonvoluntary) Intermittent dull headaches over the last 2 weeks Ears—NSA [no significant abnormalities] Eyes—NSA
Nose—NSA Throat—NSA Neck—NSA
C.R. [cardiorespiratory system]: Dyspnea on slight exertion. Palpitation on exertion. No orthopnea.
G.I. [gastrointestinal system]: See P.I.
G.U. [genitourinary system]: Frequency and nocturia, ×4 [four times] no hematuria.
Venereal disease: Denies. Menstrual history: Menarche 13 [menses began at age 13 years], q 28–30 ×5 [periods every 28–30 days lasts 5 days] of mod. heavy flow.
N.M. [neuromuscular system]: Excessive drowsiness past 2–3 weeks. Has had pp [after meals] drowsiness
past 1–2 years. Vague pains in muscles of thighs and calves.
Endocrine: See above for weakness, excessive thirst, wt. loss, nocturia, dyspnea, techycardia, etc.