Basic principles of a history

Basic principles of a history

"Listen to the patient. He is telling you the diagnosis," comes the wisdom of ages.

•To do this efficiently questions should be open-ended and allow for patients to speak freely. •Be selective with direct questioning. The patient may gloss over something that demands deeper inquiry. •Try not to interrupt unnecessarily (but there are times when it is essential to hone in on detail). •Avoid irrelevant detail. Some patients can meander aimlessly with irrelevant anecdotes and these need to be gently curtailed. •Avoid leading questions. •Let the patient speak freely in his own words.

NAME

AGE

SEX

OCCUPATION

History of presenting complaint

The main complain which bring him to hospital.

There will be a lot of complain which is the main and recent.

Enumerate the main complains as a list one by one.

MAGDI AWAD SASI 2013

Following the principles above ask:

•What is the principle complaint? Examples include dyspnoea, wheezing or cough as below.•Are there subsidiary complaints?•What is the time scale of the complaint?•Is the disease progressive or static?•Is the problem constant or paroxysmal? If it is variable, are the good times symptom free or less severe?•Are there any aggravating or relieving factors?•How severely does it affect the patient's life?

5 questions are mandatory to be asked:

1. ONSET2. DURATION3. AGGREVATING FACTORS4. RELEAVING FACTORS5. ASSOCIATED SYMPTOMS- other symptoms from

the same system of the related complain

IF THE PATIENT PRESENTED WITH PAIN , ADD 5 QS:

6. SITE7. CHARACTER/ TYPE8. REDIATION9. SEVERITY10. COURSE


FOR EXAMPLE, Dyspnoea and wheeze

The questions may apply to both dyspnoea and wheezing•When do symptoms occur?•Is there shortness of breath on exertion? How much exertion?•Is it getting worse?•Do symptoms occur at rest?•Does anything else precipitate it? This can include cold air, pollution and lying flat.•What does the patient do when it happens? He may stop for breath, he may seek fresh air, he may sit up.•Are there any undue problems with a cold? Asthma and COPD are often aggravated by a cold.

What is the importants of asking about other systems?

Remember that respiratory symptoms may be caused by disease of other systems:

•Congestive heart failure may cause dyspnoea at night. The patient sits up and throws open the windows.

•Severe anaemia causes shortness of breath on exertion.

•Neuromuscular disease can cause dyspnoea.

•Dyspnoea can be psychogenic (with features of the hyperventilation syndrome).

•Only moderate asthmatics wheeze. In severe asthma there may be no wheeze and a silent chest.


•It is important to distinguish wheeze from stridor.

2ND EXAMPLE, Cough

Questions to ask about cough include:

•Does anything bring it on? Think of the same precipitants as asthma. •When does it tend to happen? A nocturnal cough could be heart failure, a postnasal drip or gastro-oesophageal reflux. •Is it dry or productive? "Do you bring anything up?" is the question to ask the patient. •If the cough is productive, what colour is the sputum? Green or yellow suggests infection.

•"Do you ever cough up blood?" You should have a mental differential diagnosis for haemoptysis.

Remember that mild asthma can present with cough. Paroxysmal nocturnal coughing can be from heart failure. ACE inhibitors may cause cough.

3rd EXAMPLE Chest Pain

Where is the pain (l)? When did the pain first start (t)? How long does it last (t)? Does the pain radiate, if so where (q2/am)? How often do you have the pain (q2)?


How would you describe the pain - burning, pressing, stabbing, crushing, dull, aching, throbbing, sharp, constricting (q1)?

Does the pain occur at rest, with exertion, with stress, after eating, when moving your arms, or during intercourse (af/s)?

Do you have any other symptoms with the pain such as shortness of breath, palpitations, nausea, vomiting, coughing, fever, leg pain (as)?

4TH EXAMPLE Edema (dependent)

Do you have swelling in your legs? When did you first notice the swelling? Did it appear suddenly or gradually? Is the swelling worse in the morning or evening? Does the swelling decrease after a night's sleep? Do you shortness of breath associated with the swelling? Have you noticed any change in your weight? Does elevating your feel make the swelling go down? Do you have pain in your legs associated with the swelling? Do both legs swell equally? Are you taking any medications, if so, which ones?

THREE QUESTIONS NOT TO BE MISSED IN CHIEF COMPLAIN:

1. FEVER2. LOSE OF APETITE3. LOSE OF WIEGHT

Presence of the fever gives a clue that the likely cause is infection, although fever can be caused by connective tissue diseases or hematological malignancy or occult tumours.


The three symptoms of one month is likely to be tuberculosis or occult abscess in the inquired system.

Review the systems which was not mentioned in history

CVS:

Dyspnea, paroxysmal nocturnal dyspnea, orthopnea, cough, sputum , chest pain , wheeze, haemoptysis , palpitation, Pain in the calves, buttocks or thighs when walking more than a certain distance (claudication) , Tiredness (fatigue) ,Preceding sore throat, joint pain/swelling, chorea, rash , Ankle swellingRespiratory:

cough , dyspnea , sputum , wheezing , chest pain, chest tightness , haemoptysis

CNS :

Headache , diplopia , lose of vision, deafness ,dysphagia , dysarthria, dyspnae , dysphonia , dizziness , dysphasia, weakness of limbs , Unsteadiness , tremors , deviation of angle of mouth , lose of consciouscness , vomiting , sweating , parasthesia and numbness of limbs , memory disturbance , aphasia

Locomotor:


joint pain , large or small, at once or migratory , arthralgia or arthritis , skin rash , lose of hair , muscle pain , haematuria , back pain, neck pain , on / off symptoms

Genitourinary:

frequency , amount , nocturia ,polyuria, loin pain , haematuria , incontinence , decrease or increase in amount

Gastrointestinal :

Lose of apetite ,Dysphagia ,dyspepsia , epigastric pain , right hypochondrial pain , change of bowel habit , constipation , diarrhea , haematemesis ,bleeding per rectum , painful defecation

Endocrine:

Appetite and weight ,neck swelling, muscle weakness , memory disturbance , emotional liability ,sleeplessness , personality changes , palpitation, sweating , lose of libido , failure of lactation in female, lose of hair growth around face in male and axilla in female , pigmentation change increased or decreased , change of menstrual cycle , new onset of diabetes or hypertension , headache.

MULTISYSTEM COMPLAIN CAN BE


Renal failure in DIABETICS

, Connective tissues disease in young female ,

or Endocrine disease.

IN SUMMARY, KEEP IN YOUR MIND THAT THIS SYSTEMATIC INQUIRY IS HELPFUL FOR DIAGNOSIS.

It is important to ask about other body systems. There may be undiagnosed illnesses in other systems which are relevant to the respiratory symptoms.

•Loss of appetite is a common feature whenever people are unwell. It suggests that the disease is having a significant effect on wellbeing.•Significant loss of weight may well be indicative of serious illness. Remember malignancy and tuberculosis.

•Ask about urinary symptoms. Middle-aged and older women, in particular, may be less concerned about the cough than the associated stress incontinence. Ask about it as they are often too embarrassed to complain directly.

•Heart disease may cause respiratory symptoms.


Are there for example symptoms of heart failure, angina or ankle swelling?

•Rheumatoid arthritis and other connective tissue diseases may cause respiratory symptoms.

•Neuromuscular diseases may cause respiratory symptoms, particularly dyspnoea.

PAST MEDICAL AND SURGICAL HISTORY

Previous diagnosis and treatment

Between the history of the presenting complaint and past medical history, it is worth asking if there has been any previous consultation about the problem, a previous diagnosis and any previous treatment?

This may seem a little like cheating in finals but in real life it is very important. Has there been previous investigation and a diagnosis?

It may be right or it may be wrong but it is important to know about it. Has there been any previous attempt at treatment? If so, with what and how successful was it?

Blessed is he who sees the patient last.

MI, angina. Rheumatic fever. HTN, HTN of pregnancy.


Congenital heart problems. STDs, infections. Dental work (S. viridans). Investigations: angiogram. Surgery: CABG, transplant, valve replacement, angioplasty.

It is often the past history that gives the clue to the aetiology. Ask about:

•Childhood asthma, wheezing or 'bronchitis'.•Malignant disease (pulmonary metastases). Remember busulphan can cause pulmonary fibrosis.•Infections including pneumonia, tuberculosis and whooping cough.•Chest trauma and operations.•Thromboembolic disease, specifically deep vein thromboses and pulmonary embolus.

AllergiesAsk about all allergies including for example food, inhaled allergens and drugs.

Drug history

Specifically:

•Use of inhalers (assess compliance and technique).•Use of steroids (some measure of severity in asthma).


•Other drugs which may have relevance in respiratory disease (such as busulphan, ACE inhibitors, aspirin, NSAIDs).

Family history

Diseases can have a genetic component or aetiology such as asthma and cystic fibrosis. Ask also about:

•Infectious diseases such as tuberculosis (remember high risk groups).•Atopic diseases such as hay fever and eczema.•Emphysema (alpha-1-antitrypsin deficiency

Condition in a relative, what age. MI. Angina. Congenital heart dz. Mitral valve prolapse. Marfan's. DM. HTN.

Social history

•An occupational history may be very important in respiratory disease. This is highlighted with conditions such as asbestosis where there may have been exposure in the building industry for example.


It is important to ask about past occupations too. Remember an electrician, a carpenter and a sailor in the merchant navy may all have been exposed to asbestos•Hobbies and pets may also be responsible for respiratory disease.•Lifestyle and alcohol consumption are also very relevant to respiratory diseases. Ask about illicit drugs. They may be smoked or inhaled.•Smoking history should detail for example the type and number of cigarettes smoked currently and in the past.

Remember that some children start to smoke very early in life.

Ask about passive smoking.•Sexual history may be relevant to risk of HIV and AIDS.

Smoking: ever smoked, how many per day, for how long, type [cigarette, pipe, chew].

Alcohol (hypercholesteremia risk). Occupation: stress, work interruption. Activity levels. High cholesterol diet. Describe your home: stairs, etc. Who is with you there at home [help if MI, help with

tasks].

Wash hands, Introduce self, Gain consentAsk Name & Age


OH (Occupational History)PC (Presenting Complaint)HPC (History Presenting Complaint)Chest DiscomfortOnset ,Character, Location, Duration, Radiation, Severity, Precipitant or relieving factors.Had it i/n the past? Are there other pain symptoms?DyspnoeaWhat is the likely origin – heart or lungs?Is there a wheeze? Is it exertional? If chronic – do they have their normal peak flow?Is breathlessness worse lying down? Is it worse at night?Precipitating/relieving factors (how many pillows do you use?)Is the breathlessness with or without painHow far can the patient mobilise compared to pre symptoms? (NYHA)Palpitations (awareness of heart beating, or skipping)Most causes are non cardiac. What do they mean to the patient. What is the duration andwhat brings them on?Syncope (dizziness)Many causes. Could be neurological, bradycardia or arrhythmias. What brings it on? Posturalcause is unlikely to be cardiacIntermittent Claudication or cramping in the legs? Calf swelling?You would also include screening questions for peripheral vascular history/PMH (e.g. Ops, Heart problems, lung problems, Ca, High BP, diabetes, thyroid, rh. Fever)DH (Drug History) & AllergiesAny over the counter drugs or specific prescription medication? Recreational drugs?RF (Risk Factors)Smoking ,Alcohol, Cholesterol, Diet and exerciseFH (Family History)e.g. Heart disease, lung problems, high BP, CA


SH (Social History)Who is at home? Finances, Type of house etc. (2 floors?)How does this affect home life?

Ideas, Concerns & Expectations

.


Basic principles of a history

Health & Medicine

Transcript of Basic principles of a history