History taking at medical school - probably about 7 years ago

Just found some old notes I wrote for revision at medical school - they may be of use to someone although don't take them too seriously!

On re-reading some of this is just plain wrong - best bit is my notion that 'statins stop you getting fat' - pure bullshit. However some of it is mildly entertaining and may give you some decent ideas. Be careful in using this stuff and check facts. Also - warfarin IS NOT used routinely in ischaemic heart disease!

Enjoy!

History taking


· Basic Information - name, age, sex, (occupation)


· PC - Why did the patient access health care? Route of access - A&E, GP. Questions - What brought you into hospital? What has been your main problem? Should use the patients own words. No technical jargon. e.g. “I had a headache”, “I had the runs” or “I had an itchy fanny”. Probably better not to use the term ‘itchy fanny’ when actually presenting a case. PAIN is the most common presenting complaint. There are important questions to ask about pain;

1. Onset. Acute or Chronic? Gradual or sudden?
2. Duration/Timing. Is it episodic or continuous? PATTERNS?
3. Site/Radiation. Localised (somatic) or diffuse (visceral)? Does it radiate?
4. Severity. Subjective - hard to assess. Compare with common pains e.g. toothache
5. Exacerbating/Relieving factors.
6. Associated factors. Faintness, sweating, nausea, vomiting, etfuckingcetera.

· HPC - History of presenting complaint. When did patient first notice problem? How long has it been going on? Is it getting worse? If patient is in hospital what has happened to patient? Investigations. Diagnosis. Being fucked around by doctors. It’s all worth hearing. Important point - WAFFLE - if patient talks too much shite use some direct questions to elicit the specific information you require BUT be careful not to ask LEADING QUESTIONS- or your history aint shit. Your shit will be wack.

· PMH - Past medical history. What else has been going down? Rank in order of importance. E.g. 1- Diabetes 2- Broken leg 5 years ago. SHOW that you know what matters.

· DRUG HISTORY - This is a biggie, a chance to seriously impress but they have decided to not teach us any pharmacology at this medical school so you have to work it out yourself. Bummer. If the patient doesn’t know steal a peak at the drug chart. Some pointers;

1. Cardiac drugs -Nitrates, BetaBlockers, ACE inhibitors, Calcium channel blockers, Diuretics and Statins. Nitrates -symptomatic relief of chest pain. GTN. Spray or tablets. Tablets have a short shelf life so if a patient has them, they use them regularly- more severe disease. BetaBlockers - Drugs ending in -ol. Atenolol. Propanolol. ACE inhibitors - Drugs ending in -pril. Caolopril (spelt wrong). Calcium channel blockers - nipledopine. Verapemil. Diuretics -Hypertension or heart failure. Fruzamide. Benzofluzamide. Statins. Name includes the word statin. Stop you getting fat.

2. Respiratory Drugs - Relievers and preventers. Bronchodilators and steroids. Bronchodilators provide symptomatic relief and are found in BLUE inhalers. Can be taken as inhalers, tablets or nebulisers. A nebuliser suggests more severe disease, especially if it is used at home. These drugs are Beta-agonists. Salbutamol. Salmetanol. Steroids are used to prevent symptoms and are found in BROWN inhalers. Inhaled, oral, nebulised and IV. Daily oral steroids means severe disease - brand is prednizolone. Common inhaler steroids are beclomethazone and behanethlazone. A patient may have trouble with these names (I do. I can’t spell them, let alone say them. Better do something about that before I qualify) so ask them how they take their inhalers. An example could be “I take the brown in the morning and at night and I take the blue one four times a day”. You should know what that means. Also RED - strong brown. GREEN - long acting bronchodilator.

3. Anticoagulants - Aspirin, Warfarin, Heparin and L.M.W Heparin. Aspirin is generally prescribed for IHD and PVD. Standard dose is 75mg/day and it is an anti-platelet drug. Warfarin is a ‘proper’ anticoagulant. Used in IHD, PVD and when there is a history of PE or DVT. Heparin is used in a low dose subcutaneously as prophylaxis before surgery or therapeutically IV after a DVT in higher doses. L.M.W Heparin is given as a subcutaneous injection once a day. It has a longer half life meaning more consistent effects. Used to treat outpatients and DVT.

4. Proton pump inhibitors - Used for short term treatment GORD and duodenal peptic ulcers. Types include ionsoprazole and pantoprazole.

· ALLERGIES - When presenting always say no known allergies. Pets etc. important in respiratory disease. If patient says they are allergic to penicillin quantify the allergy. Has the patient experienced anaphylaxis, a rash or diarrhoea(which is only a side effect)?

· FH - Family history. Important in diabetes, heart disease, asthma, etc. Important to ask about cause of death of parents and age at death (if relevant).

· SH - Social History. Several important ones in here;

1. Smoking - VERY important. Ask “Have you ever smoked?” as they may have stopped yesterday. Ask when they started and how many they smoked a day. Express in pack years.(NB - find out how to do this)

2. Alcohol - Teetotaller vs. Drinker. Quantify - approximate weekly quantity. Any history of alcohol problems. ‘Social drinker’ is meaningless and must be clarified. If necessary go through a week day by day. 1 unit =10mls pure alcohol. X% proof = x units of alcohol per litre.

3. Employment - Occupational exposure to hazards. Miners, brass workers, farmers, carpenters, etc.

4. Illicit drug use - smack. Crack. Dope. Coke. Acid. Speed. Banana skins. Cinnamon sticks. The sad list goes on.

5. Sexual risk - where appropriate. Not for old ladies with broken hips unless someone has been ‘booming granny’ in the shower. Best to be direct and frank whiles showing due sensitivity.

6. Pets - Important in many allergic conditions. Birds in Chronic extrinsic allergic alveolitis.

7. Family -Husband/wife/children. Who is at home?

8. Mobility & Housing - Can they get to the shops? Do they live at the top of a tower block? Who does the shopping? Do they have to sleep downstairs?



SPECIFIC QUESTIONS FOR EACH SYSTEM

· CARDIOVASCULAR- chest pain, breathlessness, oedema, palpitations and syncope.
1. Chest pain - “What causes the pain?”. Standard pain questions. “Is it worse in cold weather?” “Is it worse after a big meal?” “Does it stop when you rest?” “Does it happen when you are excited/upset?”
2. Breathlessness - “Do you ever feel short of breath?” “Does this happen on exertion?” “How much can you do before feeling breathless?” Orthopnoea “Do you ever wake up feeling breathless?” “How many pillows do you sleep on?” Paroxysmal nocturnal dyspnoea “Do you have to sit up when this happens? COPD “Do you cough or wheeze when you are breathless?”
3. Palpitations - “Can you tap out the rhythm at which your heart beats?” “Is the heart beat regular or irregular?” “Is there anything that triggers an attack?” “What do you do when you have an attack?” Ectopic beats are more apparent when the heart rate is slow. Paroxysmal tachycardias often triggered by specific movements. “Are there any foods that make symptoms worse?” Ask about medication.
4. Syncope - Where possible history should be taken from an observer. “What exactly happened?” “Did you have any warning of the attack?” “How quickly did you recover?” “Did you go pale or red during the attack?” Medication
5. Oedema - “Have you notice any swelling?” ANKLE SWELLING
6. Claudication - “Have you noticed any pain in your legs?”

· RESPIRATORY - Cough, sputum, haemoptysis, chest pain, breathlessness and wheeze.
1. Cough - “Is it productive?”, “How long has the cough been present?”, “Is it worse at different times of day?” -Asthma. “Does anything trigger the cough?”
2. Sputum - Colour is important. White or grey means smoking, chronic bronchitis or asthma. Yellow or green means infection. Frothy and blood streaked suggests pulmonary oedema. How much is produced?
3. Haemoptysis - Sign of serious lung disease. Bronchial carcinoma. Pulmonary embolism. Tuberculosis. Brochiectasis. Pneumonia. Pulmonary oedema. Establish time course. Small amount over several weeks indicates cancer.
4. Chest pain - Pleuritic pain characteristically sharp, stabbing and worse on deep breaths.
5. Breathlessness - “Is breathlessness recent or has it been present for some time?” “Is it constant or does it come and go?” “Does it stop you doing anything?” Better/worse?
6. Wheeze - A high pitched whistling sound. Airway narrowing. Asthma Episodic wheeze. Chronic obstructive bronchitis and emphysema.
7. Asthma - what affects asthma. Emotional involvement. Waking at night. Cigarette smoke. Household sprays. Lost time from work/school. Sweeping/dusting. Animals.


· GIT- Altered bowel habit. Dysphagia. Blood. Pain. Vomiting.
1. Altered bowel habit - Constipation vs. Diarrhoea. Establish normal stool frequency. Constipation. Patient often reports feeling unsatisfied? How long? Straining? Associated pain, distension, nausea or vomiting? Large stools vs. Small, pellet shaped. Small, hard stools indicate constipation. Any diarrhoea? Drugs such as codeine or other opiates? Diarrhoea. How many stools daily? How long? Waking from sleep? Colour/consistency. Blood/mucus. Foreign travel/contact with diarrhoea. Associated nausea, vomiting, weight loss or pain. Purgative abuse. Antibiotics. Steatorrhoea. Pale, smelly stool difficult to flush. Fat malabsorption. Chronic pancreatitis.
2. Dysphagia - Difficulty in swallowing. At what level does the food stick?. Time course. Intermittent or progressive. Are both food and drink equally difficult to swallow? Is there a history of reflux symptoms? Odynophagia. Pain on swallowing. Spasm of oesophagus.
3. Blood - Rectal bleeding or Haematemesis. Rectal bleeding seen in several disorders. History not of much diagnostic value. Colour. Bright red from sigmoid colon and rectum. Darker red/maroon from more proximal colon. Blood coats stool and is more noticeable on toilet roll. Melena. Sticky black stools with consistency/colour of tar. Haematemesis indicates bleeding from oesophagus, stomach or duodenum. If bleeding is brisk vomit heavily bloodstained. Slower bleed lets gastric acid react with haemoglobin turning it dark brown/coffee ground colour.
4. Pain - Dull ache to cramp, colic and peritonitis. Visceral pain. Dull ache. Gnawing. Cramping. Always perceived near the midline. Can be localised to epigastric, periumbilical or suprapubic depending on embryological origin of organ. May radiate. Colic. Visceral pain caused by excessive constant contraction of a hollow, muscular organ. Builds to a peak then fades away. In smaller organs colic is soon replaced by constant pain. Movement does not aggravate visceral pain so patient may writhe or double up in response to it. Well localised pain is likely peritonitis. Pain can move from visceral to parietal in conditions such as appendicitis.
5. Vomiting - Worse in morning? Relation to meals? Associated pain. Blood/bile in vomit. Recognisable food/coffee grounds. Drugs.

· GU - Frequency. Dysuria. Nocturia. Haematuria.
1. Frequency - Desire to pass urine more than normal. Not necessarily an increase in volume. Urgency often associated.
2. Dysuria - Pain prior to, during or after micturation. UTI - burning sensation. Urinary stones or obstruction
3. Nocturia - Incomplete bladder voiding in prostate disease.
4. Haematuria - may be obvious.