18-01-23 – History taking – Abdomen (Watch lecture for practise questions) COPY

Question 1

Learning outcomes

Answer 1

• To demonstrate an understanding of how patients with GI problems present
• To demonstrate an understanding of the causes of common GI symptoms
• To understand how different body systems inter-relate
• To be able to ask relevant GI questions in a medical history

Question 2

Watch lecture for practise questions

Question 3

What are the 6 stages of the traditional medical model?

Answer 3

• 6 stages of the traditional medical model:
1) History
2) Examination
3) Investigation
4) Diagnosis
5) Treatment
6) Follow up

Question 4

What are the 5 stages of the Roger Neighbour Inner Consultation Model 1987?

Answer 4

• This model asks the same questions as the traditional method, but in a different order

• 5 stages of the Roger Neighbour Inner Consultation Model 1987:

1) Connecting
• Building rapport
• Identifying patients views beliefs and expectations

2) Summarising
• Explaining back to the patient what they have told you
• Allow for correction/development of ideas and understanding

3) Handing over
• Agreeing on doctor’s and patient’s agendas
• Involves negotiating and influencing shared management plan
• Giving ownership and responsibility of management plan to patient

4) Safety netting
• Providing advice on what to do if things get worse
• Could be a follow up, advice, or referral
• For the benefit of both doctor and patient
• Ensures ill patients stay in the medical system

5) Housekeeping
• Looking after yourself as a doctor e.g coffee or going for a walk
• Ensures you can provide a high level of care for every patient you see

Question 5

What are the 7 stages for the structure of history taking?

Answer 5

• 7 stages of history taking:
1) Presenting complaint (PC)
2) History of presenting complaint (HPC)
3) Past Medial History (PMH)
4) Drug History (DH)
5) Family History (FH)
6) Social history (SH)
7) Systems Inquiry (SE)

Question 6

How do you start the presenting complaint section (PC) of history taking?

What do you then do?

What is it important to do when doing this?

Answer 6

• The presenting complaint section of history taking should start with an open-ended question
• Examples:
1) Can you tell me a little bit about why you have come in today?
2) Can you tell me what brought you here today?
3) What can I do to help you today?

• It is then important to get a description of symptoms from the patient
• It is important to use the patients’ own words, and get everything down in one sentence e.g cough, sore throat, tummy pain, sore chest

Question 7

What is it important to establish during history of presenting complaint (HPC)?

What is it important to do during this section?

How can patient conversation be facilitated?

What 2 questions should be constantly be thinking in HPC?

What is a useful 8-part mnemonic for when patients present with pain during the History of presenting complaint (HPC) section?

Answer 7

• During history of presenting complaint, it is important to establish a timeline of events from the first symptom to the time of the interview
• Is it important to allow the patient to speak, and not jump in during this section
• Also important to facilitate the patient giving their account by asking a mix of open and close questions
* Be constantly thinking:
1) What are the possible diagnoses?
2) What else do I need to know to help decide which diagnosis is the correct one?

• Useful 8-part mnemonic for when patients present with pain during the History of presenting complaint (HPC) section:
  • S – Site – location of pain
  • O – Onset – when the pain started, what is sudden or gradual?
  • C – Character – shooting, stabbing, dull ache, throbbing pain
  • R – Radiation – see if pain radiates away from source
  • A – Associated symptoms – give examples
  • T – Timing – pain worse at a particular time? Is it constant or intermittent?
  • E – exacerbators/relievers – What makes the pain better/worse
  • S – severity – pain on a 1-10 rating

Question 8

What 4 questions we ask about systemic upset?

What can systemic upset indicate?

Answer 8

• 4 questions we ask about systemic upset:
1) Change in appetite
2) Weight loss
3) Fever – probably means infection
4) Tiredness / lethargy

• Systemic upset could indicate malignancy

Question 9

What 11 things do the HPC questions for GI system (abdomen) concern?

Answer 9

• 11 things the HPC questions for GI system (abdomen) concern:
1) Mouth symptoms
2) Abdominal pain
3) Anorexia and weight change
4) Heartburn and reflux
5) Dyspepsia and indigestion
6) Odynophagia and dysphagia
7) Abdominal distension and swellings / lumps
8) Nausea and vomiting
9) GI tract bleeding
10) Jaundice
11) Change in bowel habit – constipation / diarrhoea

Question 10

What 5 mouth symptoms are associated with GI problems?

Answer 10

• 5 mouth symptoms are associated with GI problems:

1) Bad breath – halitosis – secondary to gingival (gingivitis), dental, pharyngeal infection

2) Dry mouth – xerostomia

3) Altered taste – dysgeusia

4) Foul taste – cacogeusia

5) Cracked painful lips – inflammation of mucous membranes of mouth – stomatitis

Question 11

What are 4 different questions we ask about regarding pain in the abdomen?

What 8 part pneumonic can we then use for pain?

Answer 11

• 4 different questions we ask about regarding pain in the abdomen:

1) Does it stop them doing anything?

2) Are they lying still or writhing around?

3) Do symptoms tie in with signs?

4) Does what they say fit with how they look?

• We can then use the pneumonic SOCRATES for pain

Question 12

What 3 ways can we divide up ‘Site’ when talking about the abdomen in Socrates (in picture)?

Answer 12

• 3 ways can we divide up ‘Site’ when talking about the abdomen in Socrates (in picture):
1) 9 regions
2) 4 quadrants
3) Epigastric, periumbilical. Pelvic region
 

Question 13

How can we ask about character of pain?

What options might we give if needed?

What should we look for in the patient’s hands?

Answer 13

• To ask about character of pain, ask an open question such as ‘how would you describe the type of pain?’

• Options we may give if needed:
1) Sharp
2) Dull
3) Burning
4) Throbbing
5) Stabbing
6) Colicky – common pain associated with GI due to peristaltic effect of muscles
7) Crampy

• Watch their hands again - do they use a single finger, spread out their hand, ball up their fist?

Question 14

What could radiation of pain indicate in the GIT?

Answer 14

• Radiation of pain to the back could indicate pancreatitis
• Radiation of pain to the shoulder tip could indicate diaphragmatic irritation – referred pain from the phrenic nerve

Question 15

What are 5 common associated symptoms with GI problems? What symptoms can GI malignancy/blockages/infections present with?

What additional symptom should we ask about?

Answer 15

• 5 common associated symptoms with GI problems:
1) Sweating / Fevers
2) Vomiting /nausea
3) Diarrhoea
4) Urinary symptoms
5) Vaginal bleeding / discharge

• Malignancy/blockage can lead to abdominal distension, vomiting, and constipation
• GI infection can lead to abdominal pain, diarrhoea and vomiting
• It is also important that we ask about weight loss, as this could indicate malignancy

Question 16

What 4 questions should we ask about Timing?

Answer 16

• 4 questions should we ask about Timing:

1) When did it happen? (date, time)

2) Is it still happening now? (on going)

3) How long did it last for? (mins/hours/days/weeks/months/years)

4) How often is it occurring (one off, once a day, once a week etc.)

Question 17

What are 4 common GI condition aggravating/exacerbating factors?

What are 4 common GI condition relieving factors?

Answer 17

• 4 common GI condition aggravating/exacerbating factors:
1) Eating / not eating – eating fatty food worsens pain from gallstones
2) Movement / lack of movement
3) Position
4) Exercise (think cardiac disease)

• 4 common GI condition relieving factors:
1) Eating / not eating – acid symptoms – relief with drinking milk
2) Vomiting / opening bowels
3) Movement / lack of movement
4) Position

Question 18

How is severity graded?

Answer 18

• Severity is graded using a Use a 0-10 rating scale
• 0 = no pain
• 10 = worst pain ever had

Question 19

3 examples of using SOCRATES for GIT problems

Answer 19

• 3 examples of using SOCRATES for GIT problems:

1) Colicky RUQ pain, severe, radiating to below right scapula; consider biliary colic (abdominal pain due to gallstones) and gallstones

2) Epigastric pain with associated mass + dysphagia; consider gastric carcinoma

3) Gnawing epigastric pain, remission for weeks/months, exac. by food, radiating into back consider peptic ulcer

Question 20

What do we have to ask about regarding weight in patients with GI problems?

What is anorexia?

What 6 questions might we ask about regarding weight/appetite?

Answer 20

• In way patients with GI problems, we ask about weight loss or gain
• Anorexia = reduction in appetite +/or lack of interest in food
• Patients may or may not have noticed

• 6 questions might we ask about regarding weight/appetite:

1) ‘How’s your appetite?’ / ‘Has it changed?’ / ‘Over how long?’

2) ‘Do you still enjoy food/ meals?’

3) ‘Has your weight changed?’ / ‘Over how long?’

4) ‘Have you been trying to lose weight?’

5) ‘Are your clothes looser / tighter than normal?’

6) ‘Are you still using the same notch on your belt?’

Question 21

What are 4 causes of weight gain?

What can weight loss (RED FLAG) indicate?

What are 5 causes of weight loss?

Answer 21

• 4 causes of weight gain:

1) Fluid gain e.g. cardiac failure, liver disease, nephrotic syndrome

2) Hypothyroidism

3) Depression

4) Increased energy input/ output ratio

• Weight loss (RED FLAG) is a non-specific symptom, but may be indicative of a serious underlying pathology

• 5 causes of weight loss:

1) Malignancy

2) Malabsorption e.g. chronic pancreatitis / coeliac disease / Crohn’s disease

3) Metabolic diseases e.g. diabetes, hyperthyroidism, renal disease, chronic infection (TB/ HIV)

4) Psychiatric causes e.g. depression / dementia / anorexia nervosa

5) Malnutrition

Question 22

What is heart burn?

What might it be exacerbated by?

What is it associated with?

What is water brash?

What can it indicate if heartburn and reflux are the principal symptom?

What do we need to differentiate heart burn pain from?

Answer 22

• Heart burn is hot burning retrosternal discomfort
• May be exacerbated by food, lying flat or bending forwards
• Associated with water brash and acid taste
• Water brash occurs when a person produces an excessive amount of saliva that mixes with stomach acids that have risen to the throat
• If heartburn and reflux are the principal symptoms, GORD is likely
• Gastro-oesophageal reflux disease (GORD) is a common condition, where acid from the stomach leaks up into the oesophagus (gullet)
• We need to differentiate heart burn pain from cardiac pain

Question 23

What is dyspepsia?

What is it exacerbated and relieved by?

What is it associated with?

What should we do when the patient uses the term ‘indigestion’?

Answer 23

• Dyspepsia is pain or discomfort centred in upper abdomen
• Exacerbated by food – relieved by antacid (e.g. Gaviscon)
• Associated with nausea, belching, bloating
• Patients commonly use the term indigestion, which is ill-defined, so we need to clarify what they mean

Question 24

What is odynophagia?

What is it exacerbated by?

What can it by associated with?

What are 3 potential causes of odynophagia?

Answer 24

• Odynophagia is pain on swallowing
• It is exacerbated by hot liquids
• Odynophagia can be associated with dysphagia (swallowing difficulties)

• 3 potential causes of odynophagia:
1) Oesophageal ulcers
2) Oesophagitis
3) Oesophageal candidiasis

Question 25

What is dysphagia (RED FLAG)?

What should we do when hearing about this?

What should we not confuse this with?

What 6 questions should we ask about dysphagia?

Answer 25

• Dysphagia (RED FLAG) means difficulty in swallowing
• It is a sensation of obstruction during passage of liquid or solid food through pharynx or oesophagus
• We should always investigate this further
• We should not confuse this with ‘globus’ sensation, which is a lump in the back of the throat, and can be aided by reassurance and comfort

• 6 questions we should ask about dysphagia:
1) Where do they feel it sticking?
2) Intermittent / progressive?
3) Solids / liquids?
4) Associated symptoms e.g. heartburn / weight loss
5) Pain- odynophagia
6) Complete obstruction and regurgitation of foodstuffs?

Question 26

Causes of dysphagia:
1) Oral (4)
2) Neurological (3)
3) Neuromuscular (4)
4) Mechanical (5)

Answer 26

• Causes of dysphagia:

• 4 Oral causes of dysphagia:
1) Painful mouth ulcers
2) Tonsillitis
3) Pharyngitis
4) Glandular fever

• 3 Neurological causes of dysphagia

1) CVA

1) Bulbar palsy
• Bilateral impairment of function of the lower cranial nerves IX, X, XI and XII

2) Pseudobulbar palsy
• Bilateral supranuclear (UMN) lesions of lower cranial nerves producing weakness of the tongue and pharyngeal muscles

• 4 Neuromuscular causes of dysphagia

1) Achalasia
• Rare disorder of the food pipe (oesophagus), which can make it difficult to swallow food and drink

2) Pharyngeal pouch
• A pharyngeal pouch, also known as Zenker’s diverticulum, is a sac or pocket which can develop between the lower part of the throat (pharynx) and the upper part of the gullet or food pipe (oesophagus)

3) Myasthenia Gravis
• Myasthenia gravis is a chronic autoimmune, neuromuscular disease that causes weakness in the skeletal muscles that worsens after periods of activity and improves after periods of rest.
• These muscles are responsible for functions involving breathing and moving parts of the body, including the arms and legs

4) Diffuse oesophageal spasm

• 5 mechanical causes of dysphagia:
1) Oesophageal carcinoma
2) Gastric cancer (upper)
3) Peptic oesophagitis
4) Benign stricture (narrowing of oesophagus)
5) Extrinsic compression (e.g. lung tumour,lymph nodes, goitre)

Question 27

What are causes of nausea/vomiting?

What 4 questions should we ask about nausea and vomiting?

What are 3 types of vomitus?

Answer 27

• Nausea/vomiting is a common symptom with a variety of causes

• 4 questions should we ask about nausea and vomiting:
1) Ask about other symptoms e.g. abdominal pain / diarrhoea / constipation etc.
2) Any changes to medication?
3) Frequency and duration?
4) Pregnant?

• 3 types of vomitus (matter that has been vomited):
1) Food
2) Bile
3) Blood- ‘coffee ground’ or fresh red

Question 28

What can upper GI tract bleeding lead to?

What should we do when we find out about this?

What are 6 causes of haematemesis?

Answer 28

• Upper GI tract bleeding can lead to Melaena (passage of black tarry stools – RED FLAGS) haematemesis (vomiting blood - fresh red or ‘coffee-ground’)
• We should note any associated symptoms when finding this out

• 6 causes of haematemesis:

1) Gastric or duodenal ulcer (50% of cases)

2) Gastric erosions (15-20%)

3) Varices (10-20%)

4) Mallory-Weiss syndrome (5- 10%)

5) Reflux oesophagitis (2-5%)

6) Gastric carcinoma (uncommon)

Question 29

What is Melaena (RED FLAG)?

What is it usually secondary to?

What is it commonly caused by?

When will stools also appear dark?

Answer 29

• Melaena (RED FLAGS) is the passage of black tarry stools due to upper GI tract bleeding
• Melaena is usually secondary to bleed in oesophagus, stomach or duodenum
• It is most commonly caused by chronic peptic ulceration
• Stools will also appear dark when taking oral iron

Question 30

What does lower GI tract bleeding cause?

What 3 questions should we ask about passing fresh blood?

What are 6 associated symptoms of Lower GIT bleeding?

What are 5 causes of Lower GIT bleeding?

Answer 30

• Lower GIT bleeding usually leads to the passage of fresh blood

• 3 questions we should ask about passing fresh blood:
1) Duration and frequency?
2) Is it mixed with stool? (RED FLAG)
3) Associated symptoms?

• 6 associated symptoms of Lower GIT bleeding:
1) Diarrhoea
2) Constipation
3) Abdominal pain
4) Change in bowel habit
5) Weight loss
6) Rectal / anal pain

• 5 causes of Lower GIT bleeding:

1) Haemorrhoids

2) Anal fissure
• An anal fissure is a tear or open sore (ulcer) that develops in the lining of the large intestine, near the anus

3) Diverticular disease
• In diverticular disease, small bulges or pockets (diverticula) develop in the lining of the intestine.
• Diverticulitis is when these pockets become inflamed or infected.

4) Large bowel polyps or carcinoma
• Bowel polyps are small growths on the inner lining of the large intestine (colon) or rectum

5) Inflammatory bowel disease

Question 31

What is jaundice?

What are causes of Jaundice?

What 10 questions should we ask about jaundice?

What does painless jaundice suggest?

Answer 31

• Jaundice is the yellow discolouration of sclerae / skin
• There are many causes of Jaundice (Pre-hepatic / Hepatic / Post-hepatic causes)

• 10 Questions we should ask about jaundice:
1) Duration
2) Associated symptoms (pain, weight loss, fevers)
3) Colour of stool and urine
4) Travel
5) Consumption of shellfish
6) Blood transfusion
7) Alcohol consumption
8) Changes in medication
9) Intravenous drug use
10) Unprotected sex

• Painless jaundice suggests carcinoma of head of pancreas

Question 32

When should we investigated change in bowel habit (RED FLAG)?

What 6 questions should we ask about change in bowel habit?

Answer 32

• Once obvious causes have been excluded, investigate persistent (>4weeks) change in bowel habit

• 6 questions we should ask about change in bowel habit:

1) ‘Has there been any change in your bowel habit?’ ‘In what way?’

2) Duration

3) Colour of stool – mucous / fresh or altered blood

4) Constipation / diarrhoea, or mixture of both

5) Associated symptoms e.g. pain / nausea or vomiting / weight loss / appetite / tenesmus (feeling of not fully emptying bowels)

6) Changes in diet or medication / other illnesses

Question 33

What are 9 common causes of constipation?

Answer 33

• 9 common causes of constipation:
1) Diet/ dehydration
2) Painful anal conditions (e.g. anal fissure)
3) Immobility
4) Medication e.g. opiates
5) Hypothyroidism
6) Colonic / rectal carcinoma
7) Neuromuscular e.g. spinal cord disease / Parkinson’s disease
8) Hypercalcaemia (may be related to malignancy)
9) Irritable bowel syndrome

Question 34

What are 8 causes of diarrhoea?

Answer 34

• 8 causes of diarrhoea:
1) Diet
2) Stress
3) Infection e.g. viral gastroenteritis / food poisoning
4) Inflammation e.g. ulcerative colitis / Crohn’s
5) Endocrine e.g. hyperthyroidism
6) Malabsorption e.g. coeliac disease / pancreatic disease
7) Medication
8) Irritable bowel syndrome

Question 35

What are 10 upper GIT red flags?

Answer 35

• 10 upper GIT red flags:
1) Dysphagia
2) Evidence of blood loss
3) Unexplained weight loss
4) Upper abdominal or epigastric mass
5) Unexplained back pain
6) Painless jaundice
7) Persistent vomiting
8) Unexplained iron deficiency anaemia
9) Unexplained worsening dyspepsia without other symptoms if >55 yrs old
10) New onset upper GI pain if >55yrs old OR if risk factor (e.g.+ve FH)

Question 36

What is the qfit test?

What does it measure?

In what 5 cases will people need an urgent – suspicion of cancer referral?

What are 4 indications for a qfit test?

Answer 36

• Quantitative Faecal Immunochemical Test (qFIT)
• qFIT measures the amount of blood present in stool while laboratory testing to date has only identified presence of blood.
• qFIT is an adjunct to clinical assessment – as a test it has an excellent negative predictive value

• 5 cases will people need an urgent – suspicion of cancer referral:

1) Unexplained abdominal mass

2) Palpable ano-rectal mass

3) Patients with high-risk symptoms where Qfit is indicated and an incapacity that prevents the competition of the Qfit test

4) Patient declines or is unlikely to complete a qfit

5) Any patient with colorectal symptoms and qfit>10

• 4 indications for a qfit test?

1) Bleeding
• Repeated rectal bleeding without an obvious anal cause
• Any blood mixed with the stool

2) Bowel habit
• Persistent (more than four weeks) change in bowel habit especially to looser stools - not simple constipation

3) Pain
• Abdominal pain with weight loss (also consider upper GI cancer)

4) Iron deficiency anaemia
• Unexplained iron deficiency anaemia

Question 37

What are 6 questions that may be asked during the Past Medical History (PMH) section of interview?

What is the 10-part mnemonic for PMH?

Answer 37

• Information about previous illnesses during PMH:
1) Have they been to their doctor for anything before?
2) Have they ever been in hospital?
3) Have they had any operations?
4) Have they had any investigations/treatments for other health problems?
5) Establish if problems are on-going / resolves fully / managed by medication etc
6) Establish chronology and document in ordered fashion

• 10-part mnemonic for PMH
1) J - Jaundice
2) A - Anaemia and other haematological conditions
3) M - Myocardial infarct
4) T – Tuberculosis
5) H – Hypertension and heart disease
6) R – Rheumatic fever
7) E – Epilepsy
8) A – Asthma and COPD
9) D – Diabetes
10) S – Stroke

Question 38

What 4 types of drugs are considered during Drug history (DH)?

What are the 5 things considered when documenting a drug in drug history?

What must be asked regarding allergies?

What is an important allergy to keep in mind?

What is the difference between allergies and adverse effects?

Answer 38

• 4 types of drugs considered during drug history:
1) Prescribed medication
2) Over the counter medication
3) Herbal medication
4) Consider illicit drug use (recreational)

• 5 things considered when document a drug in drug history:
1) Name of drug
2) Dose
3) Route (e.g oral, intramuscular, per rectum)
4) Frequency
5) Duration

• We want to know why they are taking it and if they are takng it correctly
• Regarding allergies, we must ask “are you allergic to anything/any medicines that you know of?
• Elastoplast/latex allergies are important to keep note of
• Adverse effects are expected known side effects of drugs, and are not the intended therapeutic purpose of the drug
• Allergies to medicine are adverse drug reactions mediated by an immune response
• Medicine that can cause adverse effects (e.g stomach upset) can still be prescribed, but it depends on the severity of the effects.

Question 39

What are 6 reasons we ensure accurate medication history?

Answer 39

• 6 reasons we ensure accurate medication history:
1) Improves patient safety
2) Reduces medication errors / near misses
3) Reduces missed doses in hospital
4) Reduces delays to treatment
5) Savings to NHS from prevented errors
6) Improves therapeutic outcomes

Question 40

What are 6 golden rules of medication history taking?

Answer 40

• 6 golden rules of medication history taking:

1) Be structured – methodically collect current meds, allergies and previous adverse drug reactions

2) Engage with the patient whenever possible but find out who knows best about meds – carer?

3) Use more than one source of information to accurately confirm a patient’s medication history.

4) Be alert to use of high-risk medicines (e.g. warfarin, insulin, methotrexate) as accuracy critical in these cases.

• Warfarin can increase haemorrhage risk
• Methotrexate is on a weekly dose, not a daily dose, so a lot of room for error

5) Women of childbearing age – ask about prescribed contraception

6) Are they taking part in any clinical trials?

• Clinical trial medication use/dosage may not appear on medication list

Question 41

What question can we use to start drug taking history?

What 9 questions might we ask about each drug?

Answer 41

• To start drug taking history, we can ask “Which medicines are currently prescribed for you to take?”

• 9 questions might we ask about each drug:
1) Name of medicine?
2) Do you know what it is for?
3) What is the dose/strength?
4) What is the route?
5) Number of tablets or puffs or dose units taken?
6) Type/Form – device type? E.g spacer, auto inhaler
7) How often do you take this?
8) Any recent changes to dose / frequency?
9) Do you think you have any side effects with any of these medications?

Question 42

What are 9 other sources of information we can use about a patient’s medicines?

Answer 42

• Other sources of information we can use about a patient’s medicines:

1) Patient or family/friends/carers

2) Patient’s own medicines – can ask to see their medicines/dosette box

3) Repeat prescription slips/other lists – need to make sure its up to date

4) GP surgery staff / letter/ printout

5) Previous hospital notes/letters

6) Community pharmacy

7) Emergency Care Summary (ECS) Scotland only. (called Summary Care Record in England)

8) MAR chart – Medication Administration Records from care homes, prepared by Pharmacy

9) Substance misuse services – e.g. for methadone doses
• Methadone isn’t prescribed by general practise, but by substances misuse services
• Sometimes, dosage isn’t included, so we may have to contact them to get this information

Question 43

What are 3 questions we may ask concerning allergies?

What else can we do?

What are 3 ways of asking about adverse side-effects?

Answer 43

• 3 questions we may ask concerning allergies:
1) Are you allergic to any medicines?
2) What happened when you had these medicines?
3) Have any medicines caused a rash or difficulty breathing in the past?

• We can also check other sources of information

• 3 ways of asking about adverse side-effects:
1) Have any medicines recently been stopped and if so why?
2) Have you ever had a medicine stopped because the Dr thought it was making you worse?
3) Have you ever stopped a medicine because you felt unwell?

Question 44

What is intentional non-adherence?

What are 4 reasons for unintentional non-adherence?

Answer 44

• Intentional non-adherence– definite decision to not take medicine(s)

• 4 reasons for unintentional non-adherence:
1) Physical dexterity e.g cant reach medicine
2) Reduced vision
3) Cognitive impairment
4) Poor understanding e.g not being taught to use an inhaler properly

Question 45

What is the purpose of asking about family history (FH)?

What are 4 questions that may be asked?

What may be useful during this section?

What disease might we want to specifically ask about regarding the CV system?

What degree of relative are we most interested about?

What age range are we looking at?

Answer 45

• Asking about family history may give clues about possible genetic pre-disposition to illness

• 4 questions that may be asked regarding family history:
1) Are your parents still alive?
• If yes – how old are they? Do they have any health problems?
• If no – When did they die? What age were they? What did they die from?

2) Do you have any brothers or sisters? How old are they? Are they well/any illnesses?

3) Do you have any children? How old are they? Are they well/any illnesses?

4) Are there any health problems that run in your family?

• We want to ask if any 1st degree relatives (parents, siblings, children) have a history of cardiovascular disease at a young age
• 1st degree male relative less than 55 years
• 1st degree female relative less than 65 years
• May be useful to draw a family tree

Question 46

What are the various aspects of social history (SH) asked about?

Answer 46

1) Employment
• Are you working at the moment?
• May I ask what you do?
• What does that involve?
• Have you had any other jobs in the past?
• Has your health impacted your work at all?
• Important to consider occupation exposure e.g asbestos, excessive noise

2) Smoking
• Do you smoke at all?
• Have you ever smoke?
• If stopped, when did you stop?
• Important to calculate pack years – Packs of cigarettes smoked a day x number of years the person has smoked (20 cigarettes per pack)
• E.g 1 pack year is equal to 1 pack of cigarettes a day for a year (1x1)

3) Alcohol
• Do you drink at all?
• If yes – How often do you drink and how much?
• Try convert these to units, and be aware of recommended limits of alcohol consumption
• Men and women advised to not have more than 14 units a week on a regular basis
• Drinking should be spread across 3 or more days if 14 units is consumed regularly in a week

4) Home circumstances
• Who do they live with, or do they live alone?
• Do they live in a house / flat / bungalow, are there stairs?
• DO they have any help at home? How many carers a day
• ADLs (activities of daily living) e.g getting dressed, making food, walking up and down stairs
• This is one of the most important sections, as we want to ensure the patient has access to what they need to live in their home

5) Other questions to consider:
• Exercise/diet
• Do they have any hobbies or interests?
Do they have any pets?
• Do they drive?

Question 47

What is system enquiry?

What is the purpose of the system enquiry portion of an interview?

What are 7 systems that may be asked about?

What are symptoms we may look for?

Answer 47

• System enquiry is a couple of questions for each remaining system, which acts as a quick screening tool

• Examples of systems and symptoms:
1) CVS – palpitations, syncope (fainting/passing out)
2) RS (respiratory) – cough, mucus, shortness off breath
3) GI – change in bowels, abdominal pain
4) GU (genitourinary) – urinary systems, change in water works, LMP (last menstrual period)
5) Endocrine – lumps in neck, temperature intolerance, changes in weight
6) MS – aches / stiffness in joints / muscles / back
7) CNS – headache, fits, collapses

Question 48

What are 3 questions we ask to address ideas, concerns, and expectations of the patient?

Answer 48

• Questions to address ideas, concerns, and expectations of patient
1) Do you have any thoughts as to what the problem may be?
2) Is there anything that you are particularly worried it may be?
3) What are you hoping I will be able to do for you today?

Question 49

What is the purpose of summarising to complete a history taking?

What is important that needs to occur throughout the session?

Answer 49

• Summarising:
• Helps to clarify points
• May highlight questions you haven’t asked or misunderstanding
• Brings up main points of Presenting complaint (PC) and History of presenting complaint (HPC)
• Brings up relevant features in the remainder of history
• Brings up relevant positives/negatives from systems enquiry

• It is important to explain and gain consent for examination as appropriate