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
