2. Advanced history taking Flashcards
1
Q
fundamental considerations when taking the history
A
- what is the probable diagnosis so far? (based on symptoms, anatomical location, likely pathology/ pathophysiology, possible cause, additional questions accordingly)
- could any of these symptoms represent an urgent or dangerous diagnosis - red flag symptoms?
- could these symptoms be due to one of the mimicking diseases that can present with a great variety of symptoms in different parts of the body? e.g TB used to be a grat example of this, but HIV infx, syphilis, sarcoidosis and vasculitis are also important disease mimickers, anxiety and depression commonly present with many bodily (somatic) symptoms
- is the patient trying to tell me about something more than these symptoms alone?
2
Q
sympathetic confrontation - example
A
- if the patient appears sad, angry, or frightened, referring to this can be a tactful way ma lead to the patient volunterring appropriate information.
- if an emotional response is obtained, use emotional - handling skills (NURS) to deal with this during the interview
3
Q
NURS
A
Name of the emotion
show Understanding
deal with the issue with great Respect
show Support (e.g it makes sense you were angry after your husband left you. this must have been very difficult to deal with. can i be of any help to you now?
4
Q
personal questions to consider asking a patient
A
- Where do you live (e.g. a house, flat or
hostel)? - What work do you do now, and what
have you done in the past? - Do you get on well with people at
home? - Do you get on well with people at work?
- Do you have any money problems?
- Are you married, or have a partner, or
have you been married? - Could you tell me about your close
relationships? - Would you describe your marriage (or
living arrangements) as happy? - Has your partner ever hurt you?
- Have you been hit, kicked or physically
hurt by someone (physical abuse)? - Have you been forced to have sex
(sexual abuse)? - Would you say you have a large number
of friends? - Are you religious?
- Do you feel you are too fat or too thin?
- Has anyone in the family had problems
with psychiatric illness? - Have you ever had a nervous
breakdown? - Have you ever had any psychiatric
problem?
5
Q
questions to ask the patient who may have depression
A
- Have you been feeling sad, down or
blue? - Have you felt depressed or lost interest in
things daily for two or more weeks in the
past? - Have you ever felt like taking your own
life? (Risk of self-harm) - Do you find you wake very early in the
morning? - Has your appetite been poor recently?
- Have you lost weight recently?
- How do you feel about the future?
- Have you had trouble concentrating on
things? - Have you had guilty thoughts?
- Have you lost interest in things you usually
enjoy?
6
Q
questions to ask the patient who may have anxiety?
A
- Do you worry excessively about things?
- Do you have trouble relaxing?
- Do you have problems getting to sleep at
night? - Do you feel uncomfortable in crowded
places? - Do you worry excessively about minor
things? - Do you feel suddenly frightened, or
anxious or panicky, for no reason in
situations in which most people would not
be afraid? - Do you find you have to do things
repetitively, such as washing your hands
multiple times? - Do you have any rituals (such as checking
things) that you feel you have to do, even
though you know it may be silly? - Do you have recurrent thoughts that you
have trouble controlling?
7
Q
chronic fatigue by definition these patients have:
A
- inability to carry out normal activities because of severe fatigue that does not improve with rest
- feel worse after any exertion
- find sleep unrefreshing
- have symptoms that have lasted more than 6 months
- have syx that worsen when they stand up (orthostatic intolerance)
- often have associated symptoms such as pain syndromes, slow recovery from infections, sore throat, tender lymph nodes and food sensitivities
- commonly have associated conditions including irritable bowel syndrome and fibromyalgia
8
Q
patients with chronic fatigue syndrome, ask them about
A
- current sleep pattern, bed time
- distractions - using computer or telephone in bed
- alcohol, caffeine use before bed
- large meal late at night
- recent emotional upsets
- use of sedatives
- shift work
- daytime sleepiness (especially when driving)
- syx suggesting sleep apnoea
- arthritis causing pain at night
- restless legs
- hx of depression or main problem of early morning waking
9
Q
causes of fatigue
A
Way of living • Not enough sleep • Too much alcohol • Too much activity • Drug use e.g. alcohol Psychological • Anxiety • Worries • Depression Medical • Thyroid disease • Heart failure • Obesity • Obstructive sleep apnoea • Uncontrolled diabetes mellitus • Coeliac disease • Malignancy • Hypoxia (e.g. chronic lung disease) • Anaemia • HIV infection • Medications (e.g. beta-blockers, antidepressants, benzodiazepines)
10
Q
medically unexplained symptoms
A
common for pt to present w/ syx that cannot be explained and have had these distressing problems for years, may have had many investigations and have visited many doctors common syx of this sort include: - chest pain -fatigue -dizziness -abdominal pain -paraesthesiae and numbness -headache -back pain - dyspnoea
11
Q
somatic syx disorder and illness anxiety disorder
A
Somatic symptom disorder
1. At least one somatic symptom, present for
over 6 months and interfering with normal
life. The nature of the disorder may change
within this time
2. Excessive thoughts, behaviours and feelings
related to the symptoms
3. Disproportionate concern about seriousness of
symptoms
4. Persistent anxiety about health
5. Excessive time and energy spent on health
worries
Illness anxiety disorder
1. Preoccupation about having or acquiring an
illness
2. Somatic symptoms are absent or mild
12
Q
features of chronic subjective dizziness
A
- Symptoms of dizziness or light-headedness for
more than 3 months - No other diagnosis to explain the symptoms
- Severity varies but worse when standing or
walking and better when patient lies down - Worse with motion or moving environment
e.g. in train or car - Worse when light is dim
- Often associated with depression, anxiety,
obsessive–compulsive traits
13
Q
questions to ask the patient w/ possible MUS (medically unexplained symptoms)
A
1. What are your main problems (symptoms) at the moment? 2. How long have they been going on? What seems to make them better or worse? (Exacerbating and relieving factors, etc.) 3. How badly do the symptoms affect you? What happens on a typical day? 4. What is your main worry about this symptom? 5. What made you come in today in particular? 6. Was there something you thought I could do in particular to help? 7. Consider asking about depression and mood. 8. What tests and treatment have you had for these symptoms in the past?
14
Q
when is sexual hx important
A
- if pt has hx of urethral discharge, painful urination (dysuria), vaginal discharge, genital ulcer or rash, abdominal pain, pain on intercourse (dyspareunia) or anorectal symptoms
- if IMC, HIV or hepatitis is suspected
- ask about last day of intercourse, number of contacts, gender of partners and type of sexual activity and contacts with sex workers, was it protected sex or not
- type of sexual contact is important e.g oro-anal contact may predispose to colonic infx, rectal contact may predispose to hepatits B or C or HIV
- ask about hx of sexual abuse
- accurate answers may not be obtained until a number of consults were the pt can trust the Dr
15
Q
reproductive hx
A
ask about
- problems with infertility or w/ contraceptive use
- drugs to be stopped in order to conceive
- problems with pregnancies
- previous pregnancies and any problems associated w/ pregnancy or delivery
16
Q
questions related to the maintenance of good health for adults?
A
- Are you a smoker? When did you stop?
- Do you know what your cholesterol
level is? - Do you think you eat a healthy diet? Tell
me about your diet. - Has your blood pressure been high?
- Have you had diabetes or a raised blood
sugar level? - Do you drink alcohol? Every day? How
many drinks? - Do you do any sort of regular exercise?
- Do you think you have engaged in any
risky sexual activity? What was that? - Have you ever used illegal drugs? Which
ones? Do you use over-the-counter or
complementary medications? - What vaccinations have you had?
Include specific questions about tetanus,
influenza, pneumococcal and
meningococcal vaccination and
Haemophilus influenzae (these last three
are essential for patients who have had a
splenectomy as they are especially
vulnerable to infection with these
encapsulated organisms), hepatitis A and
B, human papilloma virus (HPV) and
travel vaccinations. - Have you had any regular screening for
breast cancer (based on family history or
from age 50 years)? - Have you had screening for colon
cancer? (From age 50 or earlier if a
relevant family history of colon cancer or
inflammatory bowel disease.) What test
was done?
17
Q
contraindications to live vaccines
A
- pregnancy
- HIV w/ CD4 count <200/μL
- haematological malignancies - leukaemia, lymphoma
- solid organ tpx recipients
- haemopoietic stem cell transplant
- cellular immunodeficiency
18
Q
Vaccine recommendations for adults (10)
disease, vaccine, indication
A
- influenza - inactivated or live attenuated -> annually for all adults (esp health workers, pregnant women and patients w/ chronic diesease)
- Varicella - live attenuated -> 2 doses 4 weeks apart if they lack varicella immunity
- DpT - inactivated -> all unvaccinated adults, 10 year booster of tetanus vaccine
- herpes zoster - live attenuated -> adults over 70 who are not IMC
- pneumococcal - inactivated -> adults over 65, smokers, splenectomy patient, patients w/ chronic illnesses
- Meningococcal - inactivated -> unvaccinated adults before splenectomy or travel
- MMR - live attenuated -> adults born in 1960 or later second dose as adult
- HPV - inactivated -> unvaccinated women to ge 26, unvaccinated men to age of 26, IMC people to age of 26
- HEP A - inactivated -> any adult who asks for it, especially travelllers to endemic areas
- HEP B - inactivated -> any adults who asks for it, especially travellers to endemic areas
19
Q
things to ask the elderly about - ADL activites of daily living
A
- can the pt bathe, use toilet, eat get dressed does the pt need help with those activities and who provides this help
- and ask about instrumental activities of daily living IADL e.g: shopping, cooking and cleaning, the use of transport and managing money and medications.
- ask about alterations made to the house (ramps, railings in the bathroom, emergency call buttons.
- ask who lives with the patient and how they seem to be coping with the patients illness.
20
Q
polypharmacy and common drug side effects in elderly people
A
- find out the drugs the patient is taking, how long and what it is used for
- class of drugs w/ common side effects
psychotropics - sedation and falls, fractures, etc
diuretics - hypokalaemia, renal dysfunction, gout
NSAIDs - exacerbation of hypertension, heart failure, chronic kidney disease
antihypertensives - postural hypotension and falls
21
Q
adherence problems due to, and questioning
A
-drug regimen being too complicated
- the disease is not associated w/ the symtoms
- drugs are too expensive
the patient is young or old
- treatment is for a psychiatric condition
-when the treatment seems ineffective
- begin with a neutral comment “ your drug regimen is quite a complicated combination of tablets, do you think you ever miss any of them? how often? do you use a pill dispensing device
22
Q
mental state
A
- questions to assess cognitive function
- is there a family hx of dementia?
- has the pt noticed problems w/ memory or w/ aspects of life. such as paying bills?
- ask about depression. severe depression can affect cognitive function
- delirium refers to confusion and altered consciousness which should not be confused w/ dementia were consciousness is not altered but there is a progressive loss of long term memory and other cognitive functions.
- if indicated perform a formal mental state examination
23
Q
specific problems in the elderly which should be noticed and asked about
A
- ask about falls and near falls
- pt uses a stick or a frame
- are there hazards in the house that increase the risk ( e.g steep and narrow stairs)
- the use of sedatives like sleeping tablets or antianxiety (anxiolytic) drugs and some antihypertensive drugs increases the risk of falls and must be assessed
- ** screening for osteoporosis is recommened for all women over the age of 65 and all men aged 70 and older.
24
Q
risk for osteoporosis
A
- under weight
- heavy alcohol use
- use of corticosteriods
- early menopause
- hx of previous fractures
