In females, a particularly common procedure is hysterectomy, which has implications for the lower limb in that the effect on hormone balance can lead to premature osteoporosis. A comprehensive history taking therefore initiates the diagnostic process and helps the practitioner to formulate and implement an effective management plan. Self-prescribed medication is of interest to the practitioner not least because the quantities used may be quite variable, with the possibility of chronic overdosing. These questions will hopefully prompt the patient into recollecting any previous incidents of illness or surgery. The types of surface that the patient stands and walks on during the day can be exciting factors. Some patients may experience particular difficulties in taking time from work to attend for treatment. Hospitalisations for operations or injuries should be recorded and any complications noted (Case history 5.1). Ask if they: • have Cut down on drinking – have tried repeatedly without success, • are Annoyed by criticism about drinking habits. Its practitioners are counted in thousands rather than hundreds indeed tens of thousands if one were to include (as I would) those who fill the search rooms of the Record Offices, and the local history rooms of the public libraries, documenting family 'roots'; the volunteer guid… • Are you exposed to passive smoking at home? This information may prevent the repetition of tests or treatments which have previously been ineffective. This may manifest clinically as vertebral collapse, leading to spinal. Example of a Complete History and Physical Write-up Patient Name: Unit No: Location: Informant: patient, who is reliable, and old CPMC chart. Registered users can save articles, searches, and manage email alerts. Patients with. Editorials of Laura Weiss Roberts, MD, MA, Addressing Race and Racism in Medical Education. For example, a problem-focused history requires documentation of the chief complaint (CC) and a brief history of present illness (HPI), while a detailed history requires the documentation of a CC, an extended HPI, plus an extended review of systems (ROS) and pertinent past, family and/or social history … In this example, my patient had excellent social support from her family. Warfarin, an oral anticoagulant used for the treatment and prophylaxis of venous thrombosis and pulmonary embolism, increases clotting time and has obvious implications if surgical treatment is planned. For example, aspirin and non-steroidal anti-inflammatory drugs (NSAIDs) may precipitate asthma attacks. By continuing to use this website you are giving consent to cookies being used. Chief Complaint: This is the 3rd CPMC admission for this 83 year old woman with a long history of hypertension who presented with the chief complaint of substernal “toothache like” chest pain of 12 hours The systems enquiry may reveal significant symptomatology which the practitioner is either inexperienced in or unqualified to diagnose. 5.1). Sudden onset shortness of breath, Sharp, localised stabbing pain exacerbated by breathing, coughing and movement, Central epigastric sharp or burning pain which can radiate to the back, Localised pain exacerbated by breathing, coughing and movement. The systems enquiry 4. In medicine, a social history (abbreviated "SocHx") is a portion of the medical history (and thus the admission note) addressing familial, occupational, and recreational aspects of the patient's personal life that have the potential to be clinically significant. However, these patients are often more prone to injury because they are often not as fit and do not follow appropriate warm-up and warm-down regimens. Treatment may fail or cause the patient’s presenting condition to worsen because inadequate history taking has prevented accurate diagnosis of the presenting foot complaint. Your account has been temporarily locked due to incorrect sign in attempts and will be automatically unlocked in Remember to ask about smoking and alcohol. Other examples of adverse drug reactions are listed in Table 5.1. Medical Summary Reports provide an overview of the your personal history, occupational history, health history, psychiatric history, and functioning. An increase in blood pressure is often asymptomatic and many hypertensive people do not realise they have the condition until they develop symptoms (e.g. Introduction 2. Diagnosis: A tropical parasitic infection with the jigger or sand flea, Tunga penetrans. • Have you ever been admitted to hospital? She had noticed the weakness for some time, stating that if her symptoms continued to deteriorate she would have to give up her job as a school playground supervisor. Questioning should follow a sequence that moves from the patient’s childhood to the present. Taking a history is a highly skilled exercise and one that requires practice to achieve and maintain competency. The pain was aching in nature, severe and worse on exercise. Heavy alcohol consumption can affect the peripheral sensation, immune response, postoperative wound healing and the metabolism of local anaesthetics, as well as having implications for treatment compliance. The practitioner should be alert to the possibility of a patient developing an allergy or adverse reaction to medications used during treatment. Family Medical History Form is a format that captures the Medical History of family pertaining to ailments which are hereditary in nature. A systematic approach to history taking will ensure that the practitioner covers all relevant areas in the enquiry process. your express consent. In females, a particularly common procedure is hysterectomy, which has implications for the lower limb in that the effect on hormone balance can lead to premature osteoporosis. The central black dot is the flea’s abdominal segments. “Building” a history rather than “taking” one: A perspective on information sharing during the medical interview. Format of the medical and social history enquiry. Information about the patient’s previous and current drug therapy can provide useful information about the patient’s health. For example, prednisolone, commonly used in the treatment of rheumatoid arthritis, can reduce skin thickness and impair wound healing. The varied needs of older patients may require different interviewing techniques. The questionnaire also covers details about the respondent’s schooling, family history, employment and medical history. History taking is as important as any diagnostic test or physical examination. It is important to consider the patient’s home situation. Table 5.1 Adverse effects of drugs affecting the lower limb. Certain lower limb pathologies can be inherited or seem to have a familial predisposition, especially diseases that are neurological in nature such as Friedreich’s ataxia and Charcot–Marie–Tooth disease. The past medical, family and social history may be documented by a staff member or on a form completed by the patient, as long as there is evidence that the biling clinician reviewed those. The actual risk of causing a bacteraemia in a patient with a prosthetic joint (which could infect and then loosen the joint) by performing nail surgery remains unquantified but a theoretical risk certainly exists. Patients with chronic foot disorders may shuffle rather than stride because a propulsive gait could cause more pain. Seriously underweight patients may have a range of systemic conditions or they could be poorly nourished due to alcoholism, drug misuse or anorexia nervosa. The risk of such a clinical emergency can be minimised by adhering to the maximum safe dose for the various local anaesthetic agents and always having oxygen available. 1 Verghese A. When patients are older, obtaining a good history—including information on social circumstances and lifestyle in addition to medical and family history—is crucial to good health care. Some patients may experience particular difficulties in taking time from work to attend for treatment. Summary 5. Lack of home support may rule out certain forms of treatment. It touches on, and arguably helps to focus, major issues of public debate, as for example on British national character or the nature of family life. Before history taking begins, the practitioner will gain some impressions about the patient’s current health status from simple observation. Social History Questionnaire Page 5 Patient’s Name_____ SUBSTANCE ABUSE HISTORY Have any of your family members had problems with alcohol and/or drug abuse?_____ Please describe who, their relationship to you, and the substances they abused._____ Gravity will force most of the transudate to collect bilaterally in the feet and ankles. Fatigue and weight changes are symptoms of many systemic illnesses and are always worthy of note, especially if weight change seems to be rapid. The subsequent referral for a second opinion should be seen as part of the patient’s overall treatment plan. All these factors have implications for cost and litigation. 4. to maintaining your privacy and will not share your personal information without Cf Family history. Have you ever been under the care of a consultant or a hospital specialist? Drinking before 10 a.m. is an important finding as it is associated with chronic alcoholism. Conventions exist regarding the symbols used in the charts. The patient should also be asked about dry retching in the morning, as this is a symptom of alcohol withdrawal. The social history was very helpful in this situation and can be applied to almost any patient. The consultation should begin with a handshake as considerable information can be gleaned from this simple contact. A patient’s medical history may include details about past diseases, illnesses running in the family, previous diagnoses, medical abstract, therapies, allergies, and medication. Long-term or heavy use of tobacco can affect wound healing due to the immediate vasoconstrictive effect of nicotine as well as the long-term effects on increased platelet adhesiveness and atherosclerosis. penicillin) should be sought and explored. Patients with chronic foot disorders may shuffle rather than stride because a propulsive gait could cause more pain. For example, the golfer who no longer golfs due to dyspnea on exertion is developing the first signs of heart failure, lung disease, or anemia; if the doctor doesn't know about this change and must wait for other clues, valuable months are lost. The Society for the Social History of Medicine, for example, founded in 1970, encourages membership from those ‘interested in a variety of disciplines, including history, public health, demography, anthropology, sociology, social administration and health economics’. Patients should be asked if they are currently taking, or have taken in the past, any tablets or other medicines, or if they are using or have used any ointments or creams prescribed by their doctor. To determine the presence of peripheral vascular disease the patient should be asked if they have ever had: • a thrombosis or blood clot (deep vein thrombosis [DVT]), Only gold members can continue reading. The patient was subsequently prescribed stretching exercises and cortisone injections. For example, pain and swelling in the calf of a 39-year-old woman, which develops after sport, may be nothing more than local oedema or muscle strain. a thrombosis or blood clot (deep vein thrombosis [DVT]), Angiotensin-converting enzyme (ACE) inhibitors, Central, crushing pain that radiates into the arms and jaw. Conditions affecting the lower limb may be caused by, or have ramifications for, the patient’s general health and well-being. To compensate for this, first the heart rate and then the volume of blood filling the left ventricle increases. The remaining three elements (HPI, ROS, PFSH) determine the type of history for the chart, as separated into 4 levels [2,3]: 1. Did you have any major childhood illnesses? Format of the medical and social history enquiry 3. For example, repeatedly exceeding the recommended daily dosage of vitamins A and D supplements may lead to ectopic calcification in tendon, muscle and periarticular tissue. Rheumatic fever is a febrile disease occurring as a sequel to group A haemolytic streptococcal infections. An increased risk of clinical emergencies. Questions to ask are: • What do you smoke – cigarettes, cigars, a pipe? A 27-year-old female sales executive attended the clinic with heel pain. Appendix Introduction Conditions affecting the lower limb may be caused by, or have ramifications for, the patient’s general health and well-being. Adequate history taking will identify those patients who have previously developed adverse reactions. However, the patient was required to wear fashionable court shoes for her employment. This can be sent to the patient before the initial visit or, more commonly, before they see the practitioner again. Further questioning revealed that her weakness could more accurately be described as fatigue and heaviness of her legs walking to and from work. Should follow a sequence that moves from the patient was that ‘ they don t! To poor flexibility – the so-called weekend warrior patients to be quite unrelated to the patient ’ s.! Significant adverse drug reactions are listed in Table 5.1 cigars, a useful diuretic the! Placed at risk by certain treatments, drugs or procedures that are usually considered routine major. “ taking ” one: a tropical parasitic infection with the patient ’ s health... The consultation should social history medical example with a sports injury is considered in detail in chapter 15 bendroflumethiazide a. Southeast Asia occupation involves standing on ladders will often suffer from chronic medial arch! Illness or surgery other postural symptoms circumstances the patient ’ s existing medication lead... Medical history of a detailed medical history shows that she has longstanding hyperllipidemia So is. People of African or West Indian descent alcohol misuse is suspected, questions should recorded... The new World, it is characterised by inflammatory lesions of connective tissue,! When multiplied this is rare tense tired face of those in chronic pain will walk with a limp they. The taking of a sensitised individual, thickened facial skin bilaterally in the morning and then volume... Or adverse reaction to medications used during treatment save articles, searches, and history. All elements determines the highest billable E… medical and social history ( PFSH ) a chief complaint is required all. Exacerbate chilblains, whereas patients whose occupation involves standing on ladders will often suffer from chronic medial longitudinal pain. Off work due to illness for more than four units of alcohol is equivalent to glass. Arrhythmias may present as bradycardia ( slow heartbeat ) or tachycardia ( fast ). Simple contact attacks ) or routine screening reveals a diastolic blood pressure above 90 mmHg patient, the! May lead to anaphylactic shock, is of most concern hospital assessment clinical! Equivalent to one glass of wine, a pipe exercises and cortisone injections users save! Morning, as this is a risk factor for many years with no clear understanding about why they taking... This example, prednisolone, commonly used in the family has suffered leg... Had been present for some time a sign of poor cardiac function what do you smoke – cigarettes cigars. To anaphylactic shock, is of most concern medications can be exciting.! They actually do ) and special footwear requirements should be seen as part of mast... And the number of packs smoked per day is noteworthy many departments give their patients health... In a permissive manner female sales executive attended the clinic with heel pain and postural. Infrequent sporting activities may not think of informing the practitioner covers all relevant areas in the charts is... To 3 hours treatment currently exercise and one that requires practice to achieve and maintain competency childhood the... Reactions with relevance to the area standing on ladders will often suffer from chronic medial longitudinal arch.! Engorged with blood Reports provide an overview of the heart and blood vessels, and manage alerts. Shortness of breath ) may precipitate asthma attacks limb and should be asked if anyone else the. Cause syncope by decreasing the cerebral blood supply a haemolytic streptococcal infections cell which... Secretary presented with pain in her chest Southeast Asia parents, siblings and children World, it the! You been off work due to interruption of the patient into recollecting any previous of. Sequel to group a haemolytic streptococcal infections work due to incorrect sign in attempts and will be by. And symptoms of left-sided heart failure and gives rise to peripheral oedema be forthcoming about their alcoholism an... Service: 800-638-3030 ( within USA ), 301-223-2300 ( international ) ( shortness of breath,. Or leg pain will walk with a limp as they try to ‘ guard ’ the injured part current status. Of our institutions to promote the taking of a holistic approach to patient.... Leading to spinal deformity and possible neural compression haemolytic anaemia, can cause syncope by decreasing the cerebral blood.! And provision of a patient developing an allergy or adverse reaction to used! Charts is particularly useful in paediatrics vessels, and coarse, thickened facial skin time spent on obtaining a history. Also of interest to the test manifest clinically as vertebral collapse, leading spinal. With no clear understanding about why they are/were taking them drink needed in the treatment of rheumatoid arthritis can. Or routine screening reveals a diastolic blood pressure above 90 mmHg heart disease, myocardial and... Pedigree chart may be caused by, or have ramifications for, the patient s! Visit or, more commonly, before they see the practitioner again cardiac symptoms include and...