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3History takingGeneral history taking . 57Cardiovascular history . . 61Respiratory history . 62Gastrointestinal history . . 66Genito-urinary history . 70Obstetric, gynaecological andsexual history . . 71Neurological history . 75Psychiatric history and mental health . 78Paediatric history . . 87Preoperation clinic . 9055

History taking3GENERAL HISTORY TAKINGTaking the history of a patient is the most important tool youwill use in diagnosing a medical problem. To be able toobtain a history that is targeted to the presenting complainttakes practice, as well as knowledge of possible differentialdiagnoses. In this chapter, we will provide you with a basicstructure for asking questions. In the following chapters, wewill provide target questions to help make a rough diagnosis. These target questions should only be used as a guide,and you should tailor them to your own style. It is alsoimportant that the ’physician-driven history-takingapproach’ must not overwhelm or ignore the patient’sagenda and their needs.General structurePresenting complaint (PC)Ask — What is the main problem that has caused you to come tohospital today?Find out the main problem/problems that have made thispatient present to you. It can sometimes be difficult to pindown the exact symptom(s) making the patient present. Ifthe patient has not come to you directly, find out why theypresented to someone else first.History of the presenting complaint (HPC) Where is it? And in the case of pain – Does it move anywhere? How would they describe the pain? – sharp, stabbing,dull, aching, squeezing? (let them use their own words). Time course. When did it start? How did it come on? Was itsudden or gradual? How did it continue? Did it come and go/worsen/improve? Does anything make it better or worse?57

3Medical Communication Skills and Law Made Easy How bad is it? Can they use a severity scale 1–10 ordescribe it in terms of how it affects their life? Did you feel anything else? First ask them an open question,then ask about specific symptoms that may also arise fromthe systems most associated with the presenting complaint.At this stage you may have an idea of the cause. You maywant to ask specific targeted questions to identify furtherevidence for your initial differential.Past medical and surgical history (PMHx) What medical problems do you suffer from currently and whatproblems have you suffered from in the past? Find out, inparticular, when were they first diagnosed. How have you been recently? Have you had any surgery? When did this happen?Ask about important diseases that the patient may haveforgotten to mention: Ischaemic heart disease (IHD), e.g. myocardial infarction(MI) Rheumatic fever Hypertension Diabetes Cerebrovascular accident (CVA) Pulmonary embolus (PE) Deep vein thrombosis (DVT) Asthma/COPD Epilepsy Jaundice Infectious conditions.Drug history (DHx) What medications are you currently on? What dose do you take?58

History taking3 How many times a day do you take it/them and at what timesof day? How do you take it/them? (oral or injection etc.) Have you any allergies?Ask if anything happens to them when they take the drug.Sometimes the patient may be intolerant to the medication.However, be aware of rashes, swelling and other signs ofanaphylaxis.Family history (FHx)Ask – Are there any diseases that run in your family?Drawing a family tree will help to illustrate this. Diseasesto watch out for are heart disease, strokes, hypertension,diabetes, cancer and genetic conditions.Social history (SHx) Do you smoke? Have you ever smoked for a significant periodof time? When did you stop? How much do you/did you smoke on average every day?Express smoking as pack years. Number of years the patienthas smoked, multiplied by the number of packs smoked perday. There are usually 20 cigarettes in a pack. How much alcohol do you drink in an average week?(express in units) What do you do for a living? Do you have any pets? Have you travelled anywhere recently? What sort of housing do you live in? Do you live with anyone else at home?Determine if they live alone in a house, flat, shelteredhousing, residential or nursing home:59

3Medical Communication Skills and Law Made Easy How are you coping at home? Are you able to cook/clean/wash/go shopping on your own or do you need help?Do you need help to move around?Do you need a walking stick/wheelchair?Do you have stairs to climb?Do you have any carers? How often do they come?Systemic enquiry (S/E)At this stage, in order to conclude the history, it is importantto ask about symptoms from systems not yet enquired aboutin the history of the presenting complaint (HPC): General: fever, weight loss, loss of appetite, lethargy Cardiovascular system: chest pain, palpitations,shortness of breath, paroxysmal nocturnal dyspnoea(sudden breathlessness during the night), orthopnoea(breathlessness on lying flat), leg swelling, nausea,sweating, dizziness, loss of consciousness Respiratory system: shortness of breath, cough,haemoptysis, wheeze, chest pain Gastrointestinal system: nausea and vomiting,haematemesis, dysphagia, heartburn, jaundice,abdominal pain, change in bowel habit, rectal bleeding,tenesmus (sensation of incomplete bowel emptying) Genito-urinary system: dysuria (pain on passing urine),frequency, terminal dribbling, urethral discharge Gynaecological system: pelvic pain, vaginal bleeding,vaginal discharge, LMP Neurological system: headaches, dizziness, loss ofconsciousness, fits, faints, funny turns, numbness,tingling, weakness, problems speaking, change in vision.Although one can use the generalised template to obtain anadequate history, we have provided a range of questions,which will be useful when addressing different symptoms.60

History taking3We have grouped the symptoms according to which physiological system they best represent, although some symptomsmay belong to more than one.CARDIOVASCULAR HISTORYChest painWhen taking a history of chest pain ask the patient: Where is the pain? Does it move anywhere? When did it start and was it a sudden or gradual onset? Whatwere you doing at the time? Since the onset, how has the pain continued – i.e. constant orcoming and going? Can you describe its character? Does anything make it better or worse? Can you grade its severity from 1 to 10? (1 is the least and 10is the most).Target questionsDo you: suffer from hypertension, diabetes, high cholesterol? Haveyou ever smoked? Do you have any family history of heartproblems such as angina or heart attack? Risk factors forischaemic heart disease (IHD)Does it hurt more on deep breathing or coughing, i.e. pleuriticchest pain? PE, pneumoniaDo you have a fever or a productive cough? PneumoniaRecent surgery, recent immobility – long haul flights, bed rest, onthe pill/HRT, current diagnosis of cancer, previously diagnosed PE/DVT, pro-clotting disorder, swollen tender legs? PE risk factorsHave you done any recent straining/lifting? Musculoskeletal/IHD61

3Medical Communication Skills and Law Made EasyDo you have any history of heartburn, hiatus hernia or refluxdisease? Gastro-oesophageal reflux disease (GORD).PalpitationsWhen taking a history of palpitations ask the patient: When did you first notice palpitations? Do they occur continuously or do they come and go (paroxysmal)? Were they fast or slow? Were they regular or irregular? Did younotice extra beats? Can you tap the beat with your hand? What were you doing at the time? Did you experience any other symptoms such as chest pain,shortness of breath, loss of consciousness/feeling faint, legswelling?Target questionsWere you very anxious? Anxiety provokedDo you have a fever? What medications are you taking? SinustachycardiaDo you have any heart murmurs or valve problems? Do you haveany thyroid problems? Do you suffer from angina? Have you had aheart attack? How much alcohol do you drink? Atrial fibrillationShortness of breath – see Respiratory history, belowLoss of consciousness – see Neurological history, p. 75.RESPIRATORY HISTORYShortness of breathWhen taking a history of shortness of breath, ask thepatient: How long have you been short of breath? Do you normally get short of breath?62

History taking3 Has it got worse recently?Did it come on suddenly or gradually?What were you doing at the time?Is there anything that makes it better or worse?How far can you walk before having to stop due tobreathlessness? Do you get short of breath on lying flat? How many pillows doyou sleep on? Do you ever wake up in the middle of the night feeling breathless?Target questionsDo you cough up anything? What colour is it? Do you have chestpain which is worse on breathing in deeply? Lower respiratorytract infection (LRTI)Do you get short of breath when lying flat or in the middle of thenight? Have you noticed your legs getting more swollen? Do youhave any known heart problems? Are you taking any water tablets(diuretics)? Are you good at taking them? Left ventricularfailureHow much do you smoke? Have you been gradually getting morebreathless for a while? Do you cough up phlegm most of the time?Chronic obstructive pulmonary disease (COPD) orinfective exacerbationDo you have sharp chest pain that is worse when you breathe in? Doyou have tender swollen legs? Have you coughed up any blood?Check if there are any other PE risk factors – recent surgery,recent immobility, long haul flights, bed rest, on the pill/HRT, current diagnosis of cancer, previously diagnosed PE/DVT, pro-clotting disorder. Pulmonary embolus (PE)Do you suffer from or have a family history of asthma, eczema,hay fever or allergies? Is it worse at night or in the morning? Doesexercise, cold air or pollen make it worse? Do you get heartburn?Asthma63

3Medical Communication Skills and Law Made EasyHave you had any recent chest injury or trauma? PneumothoraxHave you noticed any tingling? Swollen lips? Rash? Have you anyallergies? AnaphylaxisHow is your appetite? Have you noticed any weight loss? Do youfeel tired? How much do you or have you smoked? BronchialcancerCoughWhen taking a history of a cough, ask the patient: How long have you been coughing for? Do you bring anything up? What colour is it? When do you cough? Does anything make it better or worse? Have you noticed any blood in your sputum?Target questionsDo you cough up yellow/green sputum? Are you short of breath?Have you any chest pain? Fever? Any recent travel? Do you haveany pets? LRTIDo you have any history of heart problems? Do you have swollenankles, get breathless lying flat or wake up in the middle of thenight feeling breathless? Left ventricular failureDo you suffer from or have a family history of asthma, eczema,hay fever or allergies? Is it worse at night or in the morning? Doesexercise, cold air or pollen make it worse? Do you get heartburn?AsthmaHave you coughed up any blood? Do you have sharp chest painthat is worse when you breathe in? Do you have tender swollenlegs? Check on any other PE risk factors – recent surgery orrecent immobility, long haul flights, bed rest, on the pill/HRT, current diagnosis of cancer, previously diagnosedPE/DVT, clotting disorder. PE64

History taking3How is your appetite? Have you noticed any weight loss? Do youfeel tired? How much do you, or have you smoked? BronchialcancerHave you started any new medications, e.g. ACE (angiotensinconverting enzyme) inhibitorsDo you have a runny nose? Post-nasal dripWheezeWhen taking a history of a wheeze, ask the patient: How long have you been wheezy for? Do you get it all the time or only intermittently? Do you get short of breath? Is there any chest pain? Do you have a cough?Target questionsDo you suffer from or have a family history of asthma, eczema,hay fever or allergies? Is it worse at night or in the morning? Doesexercise, cold air or pollen make it worse? Do you get heartburn?AsthmaHow much do you smoke? Have you been gradually gettingmore breathless for a while? Have you coughed up phlegmmost days, for more than 3 months? For more than 2 years?COPDDo you have any history of heart problems? Do you haveswollen ankles, get breathless lying flat or wake up inthe middle of the night feeling breathless? Left ventricularfailureHave you noticed any tingling? Swollen lips? Rash? Have you anyallergies? AnaphylaxisChest pain – see Cardiovascular history, p. 61.65

3Medical Communication Skills and Law Made EasyGASTROINTESTINAL HISTORYDysphagiaWhen taking a history of dysphagia (difficulty swallowing)ask the patient: What have you found most difficult to swallow? Solids orliquids, or both? Where does the food stick? When did you first notice this? Did it come on suddenly one day or has it been a gradual process?When does it happen?Do you find it is painful to swallow? (odynophagia)Has food ever gone down the wrong way?Do you have a cough or feel short of breath?Target questionsHas there been a gradual problem with solids or liquids? How isyour appetite? Have you lost any weight? Do you smoke? Drinkalcohol? Oesophageal malignancyDo you find your swallowing problems come only every so often?Do you suffer from heartburn? Do you have problems drinking hotdrinks? Gastro-oesophageal reflux disease (GORD)Do you find your swallowing gets worse over the course of the dayand towards the end of the meal? Do you become more physicallytired and weak over the course of the day? Myasthenia gravisDo you find the skin over your fingers and lips is tight? Do yourfingers get cold, painful and change colour? Systemic sclerosisDoes it happen only intermittently? Oesophageal spasmDo you gurgle when drinking? Pharyngeal pouchAre