I 2=>General aspects of history taking

Remember

#central to practice of all branches of medicine /critical first step in determining etiology of a patient's illness->]taking a history #1st thing to do =>Introduce your self

Gathering information

1-Beginning History 🔹prepration 🔹Starting your Consultation 2-History of Presenting Symptoms 3-Past Medical History 4-Drug History 🔹concordance &adherence ,drug allergies /rxn , Non-prescribed drug use 5-Family History 6-Social History &lifestyle 🔹smoking ,alcohol , occupational history &home environment ,travel history ,sexual history 7-Systemic Enquiry 8-Closing interview ⭐️Complete history taking 1️⃣chief complaint (CC) 🖌main reason that push patient to seek for visiting physician or for help 🖌Usually single symptoms, occasionally >1 🖌eg; chest pain, palpitation, SOB, ankle swelling etc. 🖌patient describes problem in their own words,& should be recorded in their own words. 🖌What brings you here? How can I help you ?.. 🖌Short/ specific in one clear sentence communicating major/present problem/issue 🖌Timing: fever for last two weeks or since Monday 🖌Recurrent 🖌Any major disease important eg: DM ,HTN ,asthma ,IHD, pregnancy 🖌Note: should be put in patient's language 2️⃣present illness 🖌Elaborate in to chief complaint in details 🖌Ask relevant associated symptoms 🖌Have differential diagnosis in mind that Lead conversation and thoughts 🖌Decide and weight importance of minor complaints ⚠️🖌In details of present problem with time of onset /mode of evolution/any investigation/ treatment and outcome /and associated +'ve or -'ve symptoms 🖌Sequential presentation: 1]always relay story in days before visit 2]narrate in details 🖌details of symptomatic presentation: if patient has >1 symptom like chest pain, swollen leg , vomiting, take each symptom individually and follow it through fully 🖌mentioning important (-) as well Eg: pain was central crushing, radiating to left jaw, lasted <5 minutes relieved by rest, no associated symptoms with pain /never had this pain before/ no relation to food 🖌Avoid medical terminology and make use of descriptive language that is familiar to them 🖌Describe each symptom in a choronological order 3️⃣past medical history 4️⃣systemic inquiry 5️⃣family history 6️⃣drug history 7️⃣Social history

Key points

1-Encourage patients to tell the story in their own words 2-Facilitate this by using open questions 3-Ask closed questions later to clarify symptoms 4-Clarify any medical or other terms the patient uses so that you both understand what is meant 5-Ask sensitive questions in an objective and non- judgemental way 6-Check drug history and other facts with the patient's GP 7-Quantify the use of tobacco, alcohol and illicit drugs 8-Summarize your understanding of problems and reflect it back to the patient. 9-Patients' previous experience and attitude influence their symptoms and presentation. 10-You should have a good idea of the diagnosis after obtaining the history. 11-If not, you are unlikely to make one during examination

⭐️Taking history &recoding {Always record personal details}

1-name 2-marital status 📍if married ->1]have child ? 2]take contraception ? 3-sex 4-address 5-occupation 📍chemical 📍asthma 6-ethnicity 7-age 📍elderly =>Geriatrics 📍risk factor=> 1]elderly->IHD 2]young->m spasm 📍screen for HTN from 18 yr 8-record date of exam

Terms Used by patient should be clarified 🌺Common Underlying Problems 🌼Useful Distinguishing features

1️⃣Allergy 1-🌺 => True allergy (immunoglobulin E-mediated reaction) 🌼 =>Visible rash or swelling, rapid onset 2-🌺 =>Intolerance of food or drug, often with nausea / other GI upset 🌼 =>Predominantly GI symptoms 2️⃣Indigestion 1-🌺 =>Acid reflux with oesophagitis 🌼 =>Retrosternal burning, acid taste 2-Abdominal pain due to: {🌼->Site and nature of discomfort} 1]🌺 =>Peptic ulcer 🌼 =>Epigastric, relieved by eating 2]🌺=>Gastritis 🌼 =>Epigastric, with vomiting 3]🌺 =>Cholecystitis 🌼 =>Right upper quadrant, tender 4]🌺 =>Pancreatitis 🌼 =>Epigastric, severe, tender 3️⃣Arthritis 1]🌺 =>Joint pain 🌼 =>Redness or swelling of joints 2]🌺 =>Muscle pain 🌼 =>Muscle tenderness 3]🌺 =>Immobility due to prior skeletal injury 🌼 =>Deformity at site 4️⃣Catarrh 1]🌺 =>Purulent sputum from bronchitis 🌼 =>Cough, yellow or green sputum 2]🌺 =>Infected sinonasal discharge 🌼=>Yellow or green nasal discharge 3]🌺 =>Nasal blockage 🌼 =>Anosmia, prior nasal injury/polyps 5️⃣Fits 1]🌺=>Transient syncope from cardiac disease 🌼=>Witnessed pallor during syncope 2]🌺 =>Epilepsy 🌼 =>Witnessed tonic/clonic movements 3]🌺 =>Abnormal involuntary movement 🌼=>No loss of consciousness 6️⃣Dizziness 1]🌺 =>Labyrinthitis 🌼 =>Nystagmus, feeling of room spinning, with no other neurological deficit 2]🌺 =>Syncope from hypotension 🌼 =>History of palpitation or cardiac disease, postural element 3]🌺 =>Cerebrovascular event 🌼 =>Sudden onset, with other neurological deficit

Q to Ask about common symptoms

1️⃣CVS 🌻Do you ever have chest pain or tightness? 🌻Do you ever wake up during the night feeling short of breath? 🌻Have you ever noticed your heart racing or thumping? 2️⃣RS 🌻Are you ever short of breath? 🌻Have you had a cough? If so, do you cough anything up? 🌻What colour is your phlegm? 🌻Have you ever coughed up blood? 3️⃣GIT 🌻Are you troubled by indigestion or heartburn? 🌻Have you noticed any change in your bowel habit recently? 🌻Have you ever seen any blood or slime in your stools? 4️⃣GUS 🌻Do you ever have pain or difficulty passing urine? 🌻Do you have to get up at night to pass urine? If so, how often? 🌻Have you noticed any dribbling at the end of passing urine? 🌻Have your periods been quite regular? 5️⃣MSS 🌻Do you have any pain, stiffness or swelling in your joints? 🌻Do you have any difficulty walking or dressing? 6️⃣ES 🌻Do you tend to feel the heat or cold more than you used to? 🌻Have you been feeling thirstier or drinking more than usual? 7️⃣NS 🌻Have you ever had any fits, faints or blackouts? 🌻Have you noticed any numbness, weakness or clumsiness in your arms or legs?

⭐️Systematic enquiry :cardinal symptoms 🍢uncovers symptoms that may have been forgotten 🍢Start with 'Is there anything else you would like to tell me about?' Box 2.10 lists common symptoms by system 🍢Asking about all is inappropriate and takes too long, so judgement and context are used to select areas to explore in detail 🍢for example: 1]With a history of repeated infections, ask about nocturia, thirst and weight loss, which may indicate underlying uncontrolled diabetes. 2]In a patient with palpitation are there any symptoms to suggest thyrotoxicosis or is there a family history of thyroid disease? 3]Is the patient anxious or drinking too much coffee? 4]If a patient smells of alcohol, ask about related symptoms, such as numbness in the feet due to alcoholic neuropathy.

1️⃣General health 1] Wellbeing 2]Appetite 3]Weight change 4]Energy 5]Sleep 6]Mood 2️⃣Cardiovascular system 1]Chest pain on exertion (angina) 2]Breathlessness: 🖊Lying flat (orthopnoea) 🖊At night (paroxysmal nocturnal dyspnoea-PND) 🖊On minimal exertion - record how much 3]Palpitation 4]Pain in legs on walking (claudication) 5]Ankle swelling 3️⃣Respiratory system 1]Shortness of breath (exercise tolerance) 2]Blood in sputum (haemoptysis) 3]Cough 4]Chest pain (due to inspiration or coughing) 5]Wheeze 6]Sputum production (colour, amount) 4️⃣Gastrointestinal system 1]Mouth (oral ulcers, dental problems) 2]Difficulty swallowing (dysphagia - distinguish from pain on swallowing, i.e. odynophagia) 3]Nausea and vomiting 4]Vomiting blood (haematemesis) 5]Indigestion 6]Heartburn 7]Abdominal pain 8]Change in bowel habit 9]Change in colour of stools (pale, dark, tarry black, fresh blood) 5️⃣Genitourinary system 1]Pain passing urine (dysuria) 2]Frequency passing urine (at night: nocturia) 3]Blood in urine (haematuria) 4]Libido 5]Incontinence (stress and urge) 6]Sexual partners - unprotected intercourse 6️⃣Men 1]Urethral discharge 2]If appropriate->Prostatic symptoms, including difficulty starting (hesitancy): Poor stream or flow +Terminal dribbling 3]Erectile difficulties 7️⃣Women 1]Last menstrual period (consider pregnancy) 2]Timing and regularity of periods 3]Length of periods 4]Abnormal bleeding 5]Vaginal discharge 6]Contraception 7]If appropriate->Pain during intercourse (dyspareunia) 8️⃣Nervous system 1]Headaches 2]Dizziness (vertigo or lightheadedness) 3]Faints 4]Fits 5]Altered sensation {numbness of tingling (Paraesthesia)} 6]Weakness 7]Visual disturbance 8]Hearing problems (deafness, tinnitus) 9]Memory and concentration changes 9️⃣Musculoskeletal system 1]Joint pain, stiffness or swelling 2]Falls 3]Mobility 🔟Endocrine system 1]Heat or cold intolerance 2]Excessive thirst (polydipsia) 3]Change in sweating ⏸Other 1]Bleeding or bruising 2]Skin rash

Typical patterns of symptoms related to disease causation 🌺Onset of symptoms 🌼Progression of Symptoms 🍁Associated symptoms/pattern of symptoms

1️⃣Infection 🌺Usually hours, unheralded 🌼Usually fairly rapid over hours and or days 🍁Fevers, rigors, localising symptoms, e.g. pleuritic pain cough 2️⃣Inflammation 🌺May appear acutely 🌼Coming and going over weeks to months 🍁Nature may be multifocal, often with local tenderness 3️⃣Metabolic 🌺Very variable 🌼Hours to months 🍁Steady progression in severity with no remission 4️⃣Malignant 🌺Gradual, insidious 🌼Steady progression over weeks to months 🍁Weight loss, fatigue 5️⃣Toxic 🌺Abrupt 🌼Rapid 🍁 Dramatic onset of symptoms; vomiting often a feature 6️⃣Trauma 🌺Abrupt 🌼Little change from onset 🍁Diagnosis usually clear from history 7️⃣Vascular 🌺Sudden 🌼Stepwise progression with acute episodes 🍁Rapid development of associated physical signs 8️⃣Degenerative 🌺Gradual 🌼Months to years 🍁Gradual worsening with periods of more acute deterioration

Difficult situations

1️⃣Patients with communication difficulties 🍢If your patient does not speak your language, arrange to have an interpreter, remembering to address the patient and not the interpreter 🍢If your patient has hearing or speech difficulties such as dysphasia or dysarthria, consider the following: 1]Write things down for your patient if they can read 2]Involve someone who is used to communicating with your patient 3]Seek a sign language interpreter for a deaf patient skilled in sign language 2️⃣Patients with cognitive difficulties 🍢Be alert for early signs of dementia 🍢Inconsistent or hesitant responses from the patient should always prompt you to suspect and check for memory difficulties 🍢If you do suspect this, assess patient using a cognitive rating scale 🍢You may have to rely on a history from relatives or carers. 3️⃣Sensitive situations 🍢Doctors sometimes need to ask personal or sensitive questions and examine intimate parts 🍢If you are talking to a patient who may be suffering from sexual dysfunction, sexual abuse or sexually transmitted disease, broach the subject sensitively 🍢Indicate that you are going to ask questions in this area and make sure the conversation is entirely private. For example: 1]Because of what you're telling me, I need to ask you some rather personal questions. Is that OK? 2]Can I ask if you have a regular sexual partner? follow this up with: 1]Is your partner male or female? if there is no regular partner, ask sensitively: 1]How many sexual partners have you had in the past year? 2]Have you had any problems with your relationshipsor in your sex life that you would like to mention?If you need to examine intimate areas, ask permission sensitively and always secure the help of a chaperone 🍢This is always required for examination of the breasts, genitals or rectum, but may apply in some circumstances or cultures whenever you need to touch the patient 4️⃣Emotional or angry patients 🍢Ill people feel vulnerable and may become angry and frustrated about how they feel or about their treatment 🍢Staying calm and exploring reasons for their emotion often defuses the situation 🍢Although their behaviour may be challenging, never respond with anger or irritation and resist passing comment on a patient's account of prior management 🍢Recognise that your patient is upset, show empathy and understanding, and ask them to explain why: for example, 'You seem angry about something' or 'Is there something that is upsetting you?' If, despite this, their anger escalates, set boundaries on the discussion, calmly withdraw, and seek the assistance and presence of another healthcare worker as a witness for your own protection 🍢Talkative patients or those who want to deal with many things at once may respond to 'I only have a short time left with you, so what's the most important thing we need to deal with now?' If patients have a long list of symptoms, suggest 'Of the six things you've raised today, I can only deal with two, so tell me which are the most important to you and we'll deal with the rest later.' 🍢Set professional boundaries if your patient becomes overly familiar: 'Well, it would be inappropriate for me to discuss my personal issues with you. I'm here to help you so let's focus on your problem.'

Beginning history

1️⃣Preparation 🌺Read your patient's past records, if they are available, along with any referral or transfer correspondence before starting 🌺Allowing Sufficient Time =>Consultation length varies: 🔹In UK general practice average time available =12 min->usually adequate +provides doctor knows patient, family, social background 🔹In hospital, around 10 min is commonly allowed for returning outpatients->challenging for new or temporary staff unfamiliar with patient 🔹For new and complex problems a full consultation may take >=30 min 🔹For students, time spent with patients learning and practicing history taking is highly valuable, but patients appreciate advance discussion of time students need 2️⃣Starting your consultation ⭐️Introduce yourself and anyone who is with you, shaking hands if appropriate 🔸Confirm patient's name and how they prefer to be addressed {⭐️Create patient appropriately in a friendly relaxed way /Confidentiality and respect patient's privacy /Try to see things from patient point of view, understand patient anxiety, irritation, depression /Listening is very important} {privacy ,chaperone} 🔸If you are a student, inform patients; they are usually eager to help 🔸Write down facts that are easily forgotten, such as BP or family tree, but remember that writing notes must not interfere with consultation ⭐️Questioning: simple ,clear ,avoid medical terms ,open, leading, interrupting, direct Q, summerizing 🍁include : 1]using different styles of Q 2]Showing Empathy when taking a history 💐Using different styles of Q 🔹Begin with open Q such as 'How can I help you today?' or 'What has brought you along to see me today?' 🔹Listen actively and encourage patient to talk by looking interested and making encouraging comments, such as 'Tell me a bit more.' 🔹Always give impression that you have plenty of time 🔹Allow patients to tell their story in their own words, ideally without interruption 🔹You may occasionally need to interject to guide patient gently back to describing symptoms, as anxious patients commonly focus on relating events or reactions and opinions of others surrounding episode of illness rather than what they were feeling 🔹While avoiding unnecessary repetition, it may be helpful occasionally to tell patients what you think they have said and ask if your interpretation is correct (reflection) 🔹way you ask a Q is important: 1]Open Q are general invitations to talk that avoid anticipating particular answers: for example, 'What was the first thing you noticed when you became ill?' or 'Can you tell me more about that?' 2]Closed Q seek specific information and are used for clarification: for example, 'Have you had a cough today?' or 'Did you notice any blood in your bowel motions?' 3]Both types of Q have their place, and normally clinicians move gradually from open to closed Q as interview progresses 🔹following history illustrates mix of Q styles needed to elucidate a clear story: 1]When did you first feel unwell, and what did you feel? (open questioning) Well, I've been getting this funny feeling in my chest over the last few months. It's been getting worse and worse but it was really awful this morning. My husband called 999. The ambulance came and the nurse said I was having a heart attack. It was really scary. 2]When you say a 'funny feeling', can you tell me more about what it felt like? (open questioning, steering away from events and opinions back to symptoms) Well, it was here, across my chest. It was sort of tight, like something heavy sitting on my chest. 3]And did it go anywhere else? (Open but clarifying) Well, maybe up here in my neck. 4]What were you doing when it came on? (clarifying precipitating event) Just sitting in kitchen, finishing my breakfast. 5]How long was the tightness there? (closed) About an hour altogether. 6]So, you felt a tightness in your chest this morning that went on for about an hour and you also felt it in your neck? (reflection) Yes that's right. 7]Did you feel anything else at the same time? (open, not overlooking secondary symptoms) I felt a bit sick and sweaty. 💐Showing empathy when taking a history 🔹Being empathic helps your relationship with patients and improves their health outcomes 🔹Try to see problem from their point of view and convey that to them in your Q 🔹Consider a young teacher who has recently had disfiguring facial surgery to remove a benign tumour from her upper jaw. Her wound has healed but she has a drooping lower eyelid and facial swelling. She returns to work. Imagine how you would feel in this situation 🔹Express empathy through Q that show you can relate to your patient's experience: 1]So, it's 3 weeks since your operation. How is your recovery going? OK, but I still have to put drops in my eye. 2]And what about the swelling under your eye? That gets worse during the day, and sometimes by the afternoon I can't see that well. 3]And how does that feel at work? Well, it's really difficult. You know, with the kids and everything. It's all a bit awkward. 4]I can understand that that must feel pretty uncomfortable and awkward. How do you cope? Are there are any other areas that are awkward for you, maybe in other aspects of your life, like the social side?

Examples of Occupational disorders 🌼Factor 🌺Disorder 🍁Presents

1️⃣Shipyard 🛳 workers, marine engineers, plumbers and heating workers, demolition workers, joiners 🌼Asbestos dust 🌺Pleural plaques /Asbestosis /Mesothelioma /Lung cancer 🍁> 15 years later 2️⃣Stonemasons {S->S->S} 🌼Silica dust 🌺Silicosis 🍁After years 3️⃣Farmers {F->F->F} 🌼Fungus spores on mouldy hay 🌺Farmer's lung (hypersensitivity pneumonitis) 🍁After 4-18 hours 4️⃣Divers 🌼Surfacing from depth too quickly 🌺Decompression sickness /CNS, skin, bone, joint symptoms 🍁Immediately, up to 1 week 5️⃣Industrial workers 1]🌼Chemicals, e.g. chromium 🌺Dermatitis on hands 🍁Variable 2]🌼Excessive noise 🌺Sensorineural hearing loss 🍁Over months 3]🌼Vibrating tools 🌺Vibration white finger 🍁Over months 6️⃣Bakery workers 🌼Flour dust 🌺Occupational asthma 🍁Variable 7️⃣Healthcare workers 🌼Cuts, needlestick injuries 🌺Human immunodeficiency virus, hepatitis B and C 🍁Incubation period > 3 months

⭐️Characteristics of pain (SOCRATES)

1️⃣Site 1-Somatic pain 🍢often well localised 🍢e.g. sprained ankle 2-Visceral pain 🍢more diffuse 🍢e.g. angina pectoris 2️⃣Onset 🍢Speed of onset and any associated circumstances 3️⃣Character 🍢Described by adjectives 🍢e.g. 1]sharp/dull 2]burning/tingling 3]boring/ stabbing 4]crushing/tugging 5]Heaviness 6]Stretching 🍢preferably using patient's own description rather than offering suggestions 4️⃣Radiation 🍢Through local extension 🍢Referred by ashared neuronal pathway to adistant unaffected site 🍢e.g. diaphragmatic pain at shoulder tip via phrenic nerve (C3, C4) 🖌Radiation {extension} {IHD->chest &jaw} {Disc->low back &lower limb} 🖌Referred {gallbladder->shoulder =>Murphy's sign} 5️⃣Associated symptoms 🖌Should mention important (-) 1]Visual aura accompanying migraine with Aura 2]Numbness in leg with back pain suggesting n root irritation 3]Epigastric /abdomen pain associated with vomiting ,nausea ,Hotness ,diarrhea /constipation 6️⃣Timing (duration, course, pattern) 🍢Since onset 🍢Episodic or continuous: 1]If episodic, duration and frequency of attacks 2]If continuous, any changes in severity 7️⃣Exacerbating &relieving factors 🍢Circumstances in which pain is provoked or exacerbated, e.g. eating 🍢Specific activities or postures, and any avoidance measures that have been taken to prevent onset 🍢Effects of specific activities or postures, including: 1]effects of medication 2]alternative medical approaches 8️⃣Severity 🍢Difficult to assess, as so subjective 🍢Sometimes helpful to compare with other common pains, e.g. toothache 🍢Variation by day or night, during week or month, e.g. relating to the menstrual cycle 🖌compare /score of 10

importance of a clear history

⭐️1-central to practice of all branches of medicine /critical first step in determining etiology of a patient's illness=>Understanding patient's experience of illness by taking a history {Obtaining accurate history} 2- process requires ....... to yield key information leading to correct diagnosis and treatment 1]patience 2]care 3]understanding ⭐️Most of times you will actually be able to make a diagnosis based on history alone 3-In a perfect situation a calm, articulate patient would 1]clearly describe sequence and nature of their symptoms in order of their occurrence 2]understanding &answering supplementary Q where required to add detail and certainty 4-Multitude of factors may complicate encounter and confound clear communication of information ⭐️History taking =>planned professional conversation that enables patient to communicate his/her symptoms, feelings, and fears to clinician so as to obtain insight into nature of patients illness and his/her attitude towards them

Family history

⭐️Start with open Qs, such as 'Are there any illnesses that run in your family?' ⭐️It is possible that the presenting complaint directs you to a particular line of inquiry ⭐️Any familial disease/ running in families• Eg: 1]breast ca 2]IHD 3]DM 4]developmental delay 5]asthma 🌼Follow up presenting symptoms with a Q like 'Have any of your family had heart trouble?' 🌼Single-gene inherited diseases are relatively uncommon in clinical practice 🌼Even when present, autosomal recessive diseases such as cystic fibrosis usually arise in patients with healthy parents who are unaffected carriers 🌼Many other illnesses are associated with a positive family history but are not due to a single-gene disorder 🌼A further complication is that some illnesses, such as asthma and diseases caused by atheroma, are so common in UK population that their presence in family members may not greatly influence the risk to patient 🌼Document illness in first-degree relatives: that is, parents, siblings and children 🌼If you suspect inherited disorder such as haemophilia, construct a pedigree chart (book page 14), noting whether any individuals were adopted 🔹 terms 'propositus' and 'proposita' indicate the man or woman identified as the index case, around whom the pedigree chart is constructed. 🌼Ask about health of other household members, since this may suggest environmental risks to patient

Social history and lifestyle

🌺❌ medical assessment is complete without determining social circumstances of your patient 🌺may be relevant to causes of their illness and may influence management &outcome 🌺Establish who is there to support patient by asking 'Who is at home with you, or do you live alone?' 🖊For those who live alone, establish who is their next of kin and who visits regularly to support them 🌺Check if your patient is a carer for someone vulnerable who may be at risk due to your patient's illness 🌺Enquire sensitively if patient is bereaved, as this can have profound effects on a patient's health and wellbeing 🌺Next establish type &condition of patient's housing and how well it suits them, given their symptoms 🖊Patients with severe arthritis may, for example, struggle with stairs 🌺Successful management of patient in community requires these issues to be addressed 🌺include : 1]smoking 2]Alcohol 3]Occupational History &Home Environment 4]Travel History 5]Sexual History 1️⃣Smoking 🍢Among other things, tobacco use ⬆️ risk of 1]obstructive lung disease 2]cardiac and vascular disease 3]peptic ulceration intrauterine growth restriction 4]erectile dysfunction 5]range of cancers 🍢Most patients recognise that smoking harms health, so obtaining accurate history of tobacco use requires sensitivity 🍢Ask if your patient has ever smoked; if so, enquire what age they started at and whether they still smoke now 🍢Patients often play down recent use, so it is usually more helpful to ask about their 1]average # of cigarettes per day over years 2]what form of tobacco they have used (cigarettes, cigars, pipe, chewed) 🍢Convert to 'pack-years' to estimate risk of tobacco-related health problems Calculating pack-years of smokingA 'pack-year' {smoking 20 cigarettes a day (1 pack) for 1 year} = (# of cigarettes smoked per day × # of years smoking)/ 20 =...... pack-yrs 🍢Ask if they have smoked only tobacco or cannabis 🍢Never miss opportunity during history taking to encourage smoking cessation, in a positive and non-judgemental way, as a route to improved health 🍢❌ forget to ask non-smokers about their exposure to environmental tobacco smoke (passive smoking) 2️⃣Alcohol 🍢Alcohol causes extensive pathology, including 1]hepatic cirrhosis 2]encephalopathy 3]peripheral neuropathy 4]pancreatitis 5]cardiomyopathy 6]erectile dysfunction 7]injury through accidents 🍢Always ask patients if they drink alcohol but try to avoid appearing critical, as this will lead them to underestimate their intake 🍢If they do drink, ask them to describe 1]how much 2]what type (beer, wine, spirits) they drink in average week 🍢Quantity of alcohol consumed each week is 1-best estimated in units; 1 unit (10 mL of ethanol) is contained in: 1]one small glass of wine 2]half a pint of beer or lager 2-one standard measure (25 mL) of spirits 🍢Alcohol problems 1]UK Department of Health now defines hazardous drinking as anything exceeding 14 units per week for both 👱‍♂️ &👩 2]Binge drinking, involving a large amount of alcohol causing acute intoxication, is more likely to cause problems than if same amount is consumed over four or five days 3]Most authorities recommend at least 2 alcohol-free days per week 4]Alcohol dependence occurs when alcohol use takes priority over other behaviour that previously had greater value 🍢Warning signs in history /Features of alcohol dependence in history: 1-strong, often overpowering, desire to take alcohol 2-Inability to control starting or stopping drinking and amount that is drunk 3-Drinking alcohol in morning 4-Tolerance, where ⬆️ doses are needed to achieve effects originally produced by lower doses 5-withdrawal state when drinking is stopped or reduced, including {relieved by more alcohol}: 1]tremor 2]sweating 3]rapid heart rate 4]anxiety 5]insomnia 6]occasionally seizures 7]disorientation 8]hallucinations (delirium tremens) 6-Neglect of other pleasures and interests 7-Continuing to drink in spite of being aware of harmful consequences 3️⃣Occupational history and home environment 🍢Work profoundly influences health 🍢Unemployment is associated with ⬆️ morbidity &mortality while some occupations are associated with particular illnesses 🍢Ask all patients about their occupation 🍢Clarify what person does at work, especially about any chemical or dust exposure 🍢If the patient has worked with harmful materials (such asbestos or stone dust), a detailed employment record is needed, including 1]employer name 2]timing 3]extent of exposure 4]any workplace protection offered 🍢Symptoms that improve over weekend or during holidays suggest occupational disorder 🍢In home environment, hobbies may be relevant: for example 1]psittacosis pneumonia or hypersensitivity pneumonitis in those who keep birds 2]asthma in cat or rodent owners 4️⃣Travel history 🍢Returning travellers commonly present with illness 🍢They risk unusual or tropical infections, and air travel itself can precipitate certain conditions, such as 1]middle-ear problems 2]deep vein thrombosis 🍢incubation period may indicate likelihood of many illnesses but some diseases, such as vivax malaria and human immunodeficiency virus, may present a year or more after travel 🍢List locations visited and dates 🍢Note any travel vaccination and anti-malaria prophylaxis taken if affected areas were visited 5️⃣Sexual history 🍢Take a full sexual history only if context or pattern of symptoms suggests this is relevant 🍢Ask questions sensitively and objectively 🍢Signal your intentions: 'As part of your medical history, I need to ask you some questions about your relationships. Is this all right?' ⭐️social history places a disease in context of patient's life and reveals factors relevant to presenting illness ⭐️social history can be expansive, incorporating everything from childhood experiences to coffee intake ⭐️include 1-Upbringing 🖌Birth injury or complications 🖌Schooling, academic achievements or difficulties 🖌Further or higher education and training 🖌Behaviour problems 2-Home life 🖌Emotional, physical or sexual abuse 🖌Experiences of death and illness 🖌Interest and attitude of parents 3-Occupation 🖌Current and previous 🖌Exposure to hazards, e.g. chemicals, asbestos, 🖌Unemployment, reason and duration 🖌Attitude to job 4-Finance 🖌Circumstances including debts 5-Relationships &domestic circumstances 🖌Married or long-term partner 🖌Quality of relationship 🖌Problems 🖌Partner's health, occupation and attitude to patient's illness 🖌Who else is at home, any problems, e.g. health, violence? 6-House 🖌Type of home, size, owned or rented 🖌Details of home including stairs, toilets, heating, etc. 7-Community support 🖌Social services involvement, e.g. home help 🖌Attitude to needing help 8-Leisure activities 🖌Exercise, hobbies and pastimes, pets 9-Substance misuse 10-Occupational history 🖌Some occupations known to be associated w/ certain illnesses 🖌in particular, any chemical or dust exposure, protective devices and other workers have become ill 11-Tobacco 🖌Ask if your patients have ever smoked; 1]for how long 2]how much 3]when started and stopped 🖌If they smoke ask 1]what type 2]quantity (No. of cigarettes/day) 3]duration

history of presenting symptoms

🌼Ask patient to think back to start of their illness and describe what they felt and how it progressed 🌼Begin with some open Q to get your patient talking about the symptoms, gently steering them back to this topic if they stray into describing events or reactions or opinions of others 🌼As they talk, pick out 2 /3 main symptoms they are describing (such as pain, cough and shivers); these are essence of history of presenting symptoms 🌼It may help to jot these down as single words, leaving space for associated clarifications by closed questioning as history progresses 🌼Experienced clinicians make a diagnosis by recognising patterns of symptoms 🌼With experience, you will refine your Q according to presenting symptoms, using a mental list of possible diagnoses (a differential diagnosis) to guide you 🌼Clarify exactly what patients mean by any specific term they use (such as catarrh, fits or blackouts); common terms can mean different things to different patients and professionals 🌼Each answer ⬆️ /⬇️ probability of a particular diagnosis and excludes others 🔹patient is a 65-year-old male smoker. His age and smoking status ⬆️ probability of certain diagnoses related to smoking 🔹cough for 2 months ⬆️ likelihood of lung cancer and chronic obstructive pulmonary disease (COPD) 🔹Chest pain does not exclude COPD since he could have pulled a muscle on coughing, but pain may be pleuritic from infection or thromboembolism. In turn, infection could be caused by obstruction of airway by lung cancer 🔹Haemoptysis lasting 2 months greatly ⬆️ chance of lung cancer 🔹If patient has weight loss, the positive predictive value of all these answers is very high for lung cancer 🌼will focus your examination and investigation plan: 1]What was the first thing you noticed wrong when you became ill? (open question) I've had a cough that I just can't get rid of. It started after I'd had flu about 2 months ago. I thought it would get better but it hasn't and it's driving me mad. 2]Could you please tell me more about the cough (open Q) Well, it's bad all the time. I cough and cough, and bring up some phlegm. It keeps waking me at night so I feel rough the next day. Sometimes I get pains in my chest because I've been coughing so much. 3]already you have noted 'cough', 'phlegm' and 'chest pain' as headings for your history. follow up with key Q to clarify each -cough: Are you coughing to try to clear something from your chest or does it come without warning? (closed Q, clarifying) Oh, I can't stop it, even when I'm asleep it comes. Does it feel as if it starts in your throat or your chest? Can you point to where you feel it first? It's like a tickle here (points to upper sternum). -phlegm: What colour is the phlegm? (closed Q, focusing on symptom) Clear. Have you ever coughed up any blood? (closed Q) Yes, sometimes. When did it first appear and how often does it come? (closed questions) Oh, most days. I've noticed it for over a month. How much? (closed question, clarifying the symptom) Just streaks. Is it pure blood or mixed with yellow or green phlegm? Just streaks of blood in clear phlegm. -chest pain: Can you tell me about the chest pains? (open question) Well, they're here on my side (points) when I cough. Does anything else bring on the pains? (open, clarifying the symptom) Taking a deep breath, and it really hurts when I coughor sneeze 🌼Pain is a very important symptom common to many areas of practice =SOCRATES 🌼Having clarified presenting symptoms, prompt for any more associated features, using your initial impression of likely pathology (lung cancer or chronic respiratory infection) to direct relevant questions: -Do you ever feel short of breath with your cough? A bit -How has your weight been? (seeking additional confirmation of serious pathology) I've lost about a stone since this started 🌼Q required at this point will vary according to system involved 🌼Learn to think, as you listen, about broad categories of disease that may present and how these relate to history, particularly in relation to onset and rate of progression of symptoms (Box 2.4). 🌼To complete history of presenting symptoms, make initial assessment of how illness is impacting on life of your patient 🔹 breathlessness on heavy exertion may prevent a 40-year-old builder from working but would have much less impact on a sedentary retired person. 'Can you tell me how far you can walk on a good day?' is a question that can help to clarify the normal level of functioning, and 'How has this changed since you have been unwell?' can reveal disease impact. Ask if the person undertakes sports or regular exercise, and if they have modified these activities because of illness

Past medical history

🍁Past medical history may be relevant to presenting symptoms, for example: 1]previous migraine in a patient with headache 2]haematemesis and multiple minor injuries in a patient with suspected alcohol abuse 🍁It may reveal predisposing past or underlying illness, such as 1]diabetes in a patient with peripheral vascular disease 2]childhood whooping cough in someone presenting with bronchiectasis 🍁referral letter and case records often contain useful headlines but patient is usually best source 🍁Q will elicit key information in most patients: 1]What illnesses have you seen a doctor about in the past? 2]Have you been in hospital before or attended a clinic? 3]Have you had any operations? 4]Do you take any medicines regularly? ⭐️Start by asking patient if they have any medical problems: 1]IHD 2]Heart attack 3]DM 4]TB ⭐️if DM - mention time of diagnosis /current medication /clinic check up ⭐️There is often a relationship between past medical history and presenting problem ⭐️Past surgical /operation history: 1]time 2]place 3]what type of operation ⭐️note any blood transfusion and blood grouping

Closing the interview

💐Using simple language, briefly explain your interpretation of the patient's history and outline the likely possibilities 💐Be sensitive to their concerns and body language 💐Ask the patient if they already have ideas and concerns about the diagnosis , so these may be addressed directly 💐Always give the patient a final opportunity to raise additional concerns ('Is there anything else you would like to ask?') 💐Make sure patients are involved in any decisions by suggesting possible actions and encouraging them to contribute their thoughts 💐This way, you should be able to negotiate an agreed plan for further investigation and follow-up 💐Tell them that you will communicate this plan to other professionals involved in their care

Drug history

💐follows naturally from asking about past illness 💐Begin by checking any written sources of information, such as drug list on referral letter or patient record 💐It is useful to compare this with patient's own recollection of what they take 💐This can be complicated by patients' use of brand names, descriptions of tablet number and colour and so on, which should always be translated to generic pharmaceutical names and quantitative doses for patient record ⭐️Ask about prescribed drugs and other medications, including 1]over-the-counter remedies 2]herbal and homeopathic remedies 3]vitamin 4]mineral supplements 💐❌ forget to ask about inhalers and topical medications, as patients may assume that you are asking only about tablets 💐Note 1]all drug names 2]dosage regimens 3]duration of treatment 4]along with any significant adverse effects, in a clear format 💐Example of a drug history {🖌Dose ,🖊Duration ,🍢Indication ,📍Side-effects /patient concerns} 1]Aspirin 🖌75 mg daily 🖊5 years 🍢Started after myocardial infarction (MI) 📍Indigestion 2]Atenolol 🖌50 mg daily 🖊5 years 🍢Started after myocardial infarction (MI) 📍Cold hands (?adherence) 3]Co-codamol {paracetamol +codeine} 🖌8 mg /500 mg, up to 8 tablets daily 🖊4 weeks 🍢Back pain 📍Constipation 4]Salbutamol MDI {Metered-dose Inhaler} 🖌2 puffs as necessary 🖊6 months 🍢Asthma 📍Palpitation, agitation 💐When drugs such as methadone are being prescribed for addiction, ask community pharmacy to confirm dosage and to stop dispensing for duration of any hospital admission ⭐️include: 1]Concordance &Adherence 2]Drug allergies /rxns 1️⃣Concordance &adherence ⭐️traditional model of medical care where patients take their medication as prescribed by doctor ⭐️Half of all patients ❌ take prescribed medicines as directed 🖌Patients who take their medication as prescribed are said to be adherent 🖌Concordance implies that patient and doctor have negotiated and reached agreement on management, and adherence to therapy is likely (though not guaranteed) to improve 🖌Ask patients to describe how and when they take their medication 🖌Give them permission to admit that they ❌ take all their medicines by saying, for example, 'That must be difficult to remember' 2️⃣Drug allergies/reactions ⭐️Ask if your patient has ever had allergic reaction to a medication or vaccine ⭐️Ask about other allergies: 1]foodstuffs 2]animal hair 3]pollen or metal ⭐️Record true allergies prominently in patient's case records and drug chart 🖌Clarify exactly what patients mean by allergy, as intolerance (such as nausea) is much more common than true allergy 🖌Drug allergies are over-reported by patients: for example, only 1 in 7 who report a rash with penicillin will have a positive penicillin skin test 🖌Note other allergies, such as foodstuffs or pollen 🖌Record true allergies prominently in patient's case records, drug chart and computer records 🖌If patients have had a severe or life-threatening allergic reaction, advise them to wear an alert necklace or bracelet 3️⃣Non-prescribed drug use 🖌Ask all patients who may be using drugs about non-prescribed drugs 🖌In Britain about 30% of the adult population have used illegal or non-prescribed drugs (mainly cannabis) at some time 💐Useful Q ->Non-prescribed drug history 1]What drugs are you taking? 2]How often and how much? 3]How long have you been taking drugs? 4]Have you managed to stop at any time? If so, when and why did you start using drugs again? 5]What symptoms do you have if you cannot get drugs? 6]Do you ever inject? If so, where do you get the needles and syringes? 7]Do you ever share needles, syringes or other drug-taking equipment? 8]Do you see your drug use as a problem? 9]Do you want to make changes in your life or change way you use drugs? 10]Have you been checked for infections spread by drug use?