It is not uncommon for patients to have taken prescribed drugs for many years with no clear understanding about why they are/were taking them. 1 Verghese A. 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. One unit of alcohol is equivalent to one glass of wine, a single measure of spirits or half a pint of beer. A history of cardiovascular disease should be taken with respect to systemic, peripheral and haematological disease states, followed up by a review of symptomatology. Having recorded disease states of which the patient is aware, enquire further about any systemic cardiovascular symptoms. 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. 30 mins. Questions to ask are: • What do you smoke – cigarettes, cigars, a pipe? All registration fields are required. This may manifest clinically as vertebral collapse, leading to spinal. Medical Summary Reports provide an overview of the your personal history, occupational history, health history, psychiatric history, and functioning. The CAGE system is useful here – two or more positive replies identifies problem drinkers; one is an indication for further enquiry about a person’s drinking. Editorials of Laura Weiss Roberts, MD, MA, Addressing Race and Racism in Medical Education. With some types of treatment patients are required to reduce their activity level to a minimum, change dressings or administer treatments at home. Social history: smoking, alcohol, recreational drugs, accommodation and living arrangements, marital … Step 07 - Social History (SH) This is the opportunity to find out a bit more about the patient’s background. 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’. Some error has occurred while processing your request. The systems enquiry involves asking questions that will seem, to the patient, to be quite unrelated to the lower limb problem. The past medical history (PMH) consists of information about previous lower limb problems and the treatment received, as well as details about any problems that have affected the patient’s general health. For example, aspirin and non-steroidal anti-inflammatory drugs (NSAIDs) may precipitate asthma attacks. 2003;163:1134–1140. This condition can have a direct effect on the ability of the muscles to function under strain. Bare concrete floors will exacerbate chilblains, whereas patients whose occupation involves standing on ladders will often suffer from chronic medial longitudinal arch pain. Summary 5. N Engl J Med. The relationships between the history of science and the history of medicine are discussed in order to clarify the extent to which the latter can and should be modelled on the former. Author Arlene Bowers Andrews provides rich resources to assist helping professionals as they gather and–most importantly–interpret information about social relationships in the lives of individuals. Thalassaemia, another haemolytic anaemia, can affect patients from the Mediterranean and Southeast Asia. In particular, recent travel to tropical countries and details of any foot injuries sustained while walking barefoot should be recorded (Case history 5.3). Bacteraemia in patients with a history of endocarditis or rheumatic valvular disease may lead to bacterial growth on the previously damaged heart valves or endocardium. The clinician must therefore be… Ask if the visit was urban or rural and whether they had any specific vaccinations. In chronic right-sided heart failure, the peripheral oedema will eventually be infiltrated by fibrous tissue that cannot be reduced by elevation (non-pitting oedema). Cf Family history. • need an Eye opener drink needed in the morning. Patients on long-term steroid therapy can develop a ‘moon’ face. An X-ray revealed a compression fracture to the head of the first metatarsal, which has predisposed degeneration of the joint. An increased risk of clinical emergencies. A 23-year-old man attended clinic after 6 months of working as a volunteer in India. Literally, her dog caused her to seek care. A social history may include aspects of the patient's developmental, family, and medical history, as well as relevant information about life events, social class, race, religion, and occupation. 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. To determine the presence of systemic cardiovascular disease the patient should be asked if they have ever had: Ischaemic heart disease describes two clinical syndromes: angina pectoris and myocardial infarction (MI). When an individual sensitised in this way is exposed on a second occasion to the allergen, the allergen combines with the IgE antibodies on the surface of the mast cells. In this example, my patient had excellent social support from her family. When it does occur it usually follows entry of an antigenic drug into the circulation of a sensitised individual. The medical history and systems enquiry presented is based on the hospital assessment or clinical clerking system. “The patient does not smoke and drinks occasionally.” This, sadly, is the patient's social history as recorded in too many of our medical records. Because it takes longer to fill the left ventricle, the pressure in the whole cardiac pulmonary system ‘backs up’, causing pulmonary congestion, reduced blood gas exchange and eventually pulmonary oedema. The systems enquiry may reveal significant symptomatology which the practitioner is either inexperienced in or unqualified to diagnose. A 23-year-old secretary presented with pain in the first metatarsophalangeal joint. See Psychiatric history. The varied needs of older patients may require different interviewing techniques. Other less-specific systemic cardiac symptoms include fatigue and decreased exertional tolerance. 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. The following questions will reveal important information about the patient’s general health: • Are you under the doctor or consultant for any treatment currently? Diseases or abnormalities of the lower limb often present with a history of signs and symptoms which will allow the practitioner to make a provisional diagnosis. Taking a history is a highly skilled exercise and one that requires practice to achieve and maintain competency. In such cases the skin around the area of the injection shows an immediate, localised inflammatory reaction. The clinician must therefore be aware of the patient’s medical and social history as they may have implications for the diagnosis and management of lower limb problems. In particular, details of any adverse reactions, either by the patient or any member of the patient’s family, to previous local anaesthetic injections and other drugs (e.g. The patient had also noticed that climbing stairs causes a tight squeezing pain in her chest. A patient’s occupation may be a contributory cause of the lower limb problem and may influence the treatment that can be given (Case history 5.2). Details of foreign travel should be recorded in case the patient has acquired an infection while abroad. Practitioners should routinely take their patients’ blood pressure, not least because the stress caused by treatment or examination may provoke a clinical emergency in a patient with uncontrolled hypertension. The nature of previous podiatric treatment, the name of the practitioner, details of relevant investigations such as X-rays, and the patient’s view of the treatment’s success should be recorded. The pain was aching in nature, severe and worse on exercise. 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. _____ Birth/ Delivery: Was the child full term? Disorders of skin and nails may manifest themselves in the hand: for example, psoriasis and eczema may cause hypertrophy and anhydrosis of the skin; pulmonary or cyanotic heart disease may cause clubbed or hippocratic nails. penicillin) should be sought and explored. The ethnic origin of the patient should also be noted. Before history taking begins, the practitioner will gain some impressions about the patient’s current health status from simple observation. Step 3: Social History. Information about the patient’s previous and current drug therapy can provide useful information about the patient’s health. It is not known why some individuals are predisposed to anaphylaxis, though genetic mechanisms are certainly involved since there is a strong familial disposition. Active sportsmen and women may make the association between their sport and a lower limb problem, but those who participate in occasional sporting activities and hobbies may not. The subsequent referral for a second opinion should be seen as part of the patient’s overall treatment plan. Certain rhythms such as ventricular tachycardia predispose to cardiac arrest. If a patient is still under the care of a hospital consultant it is prudent to inform the consultant before any treatment is given that may affect other body systems. The range of motion of the joint was reduced, with painful crepitus evident on dorsiflexion. Comprehensive The lowest common history level met by all elements determines the highest billable E… Obesity is associated with recalcitrant heel pain and other postural symptoms. A social history questionnaire seeks to provide details about a person’s social history. For example, upper and lower motor neurone lesions may cause an ataxic gait, in which coordination and balance are impaired. A patient’s occupation may be a contributory cause of the lower limb problem and may influence the treatment that can be given (Case history 5.2). The patient should also be asked about dry retching in the morning, as this is a symptom of alcohol withdrawal. Labor history, deals with labor unions and the social history of workers.See for example Labor history of the United States The Study Group on International Labor and Working-Class History was established: 1971 and has a membership of 1000. The patient should then be asked: • Have you been off work due to illness for more than 1 week in the past 6 months? 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. It is not uncommon for patients to have taken prescribed drugs for many years with no clear understanding about why they are/were taking them. Please enable scripts and reload this page. Along with the chance to connect with the patient as a person, the social history can provide vital early clues to the presence of disease, guide physical exam and test-ordering strategies, and facilitate the provision of cost-effective, evidence-based care. Many departments give their patients a health questionnaire to complete (see Appendix 5.1). Patients should also be asked if they are currently taking or have taken in the past any tablets or medicine or used any ointments or creams which they have purchased from a chemist. Social History (SH): This is a broad category which includes: Alcohol Intake: Specify the type, quantity, frequency and duration. In CHF there is an inadequacy in the supply of oxygenated blood. Some of our readers have found that they are able to use the model of Medical Summary Reports with their own doctors, Case Workers, or Social Workers to help get approved. 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. An increased risk of clinical emergencies. Diagnosis: Traumatic arthritis. Diagnosis: Plantar fasciitis. Arrhythmias may present as bradycardia (slow heartbeat) or tachycardia (fast heartbeat) with varying degrees of irregularity. Conditions affecting the lower limb may be caused by, or have ramifications for, the patient’s general health and well-being. Cardiac disease such as arrhythmias and aortic stenosis can cause syncope by decreasing the cerebral blood supply. The patient should be asked if anyone else in the family has suffered from leg or foot problems. Format of the medical and social history enquiry, Before history taking begins, the practitioner will gain some impressions about the patient’s current health status from simple observation. Patients with acute foot or leg pain will walk with a limp as they try to ‘guard’ the injured part. 800-638-3030 (within USA), 301-223-2300 (international)
In such circumstances the patient should be informed that a second opinion is recommended. A type I hypersensitivity reaction, which may lead to anaphylactic shock, is of most concern. Are you exposed to passive smoking at home? Example of Patient Medical History Form Other examples of adverse drug reactions are listed in Table 5.1. Expanded Problem Focused 3. More than four units of alcohol per day is noteworthy. 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. It is important that patients are advised before the enquiry begins that the purpose of the questions is to ensure that there are no general health problems that may be causing the lower limb condition or that may influence the type of treatment considered. Did you have any major childhood illnesses? Each clinical case scenario allows you to work through history taking, investigations, diagnosis and management. All forms of spina bifida should be noted even if the problem has been labelled as spina bifida occulta (impaired gait, pes cavus and plantar ulceration have been found to appear late in cases of spina bifida occulta). Adequate history taking will identify those patients who have previously developed adverse reactions. Information about the patient’s previous and current drug therapy can provide useful information about the patient’s health. The social history in a medical history report needs to add if the patient has any sort of tobacco, alcohol or caffeine addiction. MEDICAL HISTORY Pregnancy: Please describe any complications, medications taken, or other concerns experienced during pregnancy (e.g., high blood pressure, toxemia, gestational diabetes, etc.) The nature of the work should be determined (what they actually do) and special footwear requirements should be noted. For one patient with COPD who came to the emergency department, the social history, with a simple question about pets, revealed crucial data. Alcohol consumption is generally measured in units. This causes immediate destruction of the mast cell, which releases its contents, specifically histamine, serotonin, platelet-activating factor and slow-reacting substance. The use of questionnaires gives patients time to consider their answers and reduces the time spent in taking a medical history during the consultation. Use of recreational drugs should be recorded. Please try after some time. 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. Rheumatic fever is a febrile disease occurring as a sequel to group A haemolytic streptococcal infections. Gait disorders in children are best visualised as the child walks into the room to meet the practitioner; children often become self-conscious when asked to walk on demand. lead to ectopic calcification in tendon, muscle and periarticular tissue. This may manifest clinically as vertebral collapse, leading to spinal deformity and possible neural compression. 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. Remember to ask about smoking and alcohol. The social history was very helpful in this situation and can be applied to almost any patient. 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… 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. Social factors can be a major hindrance for patients to be healthy. However, the patient was required to wear fashionable court shoes for her employment. Sitting down relieved the pain but prolonged sitting tended to make her ankles swell. This may be followed by a profound drop in blood pressure and life-threatening cardiovascular depression. Some patients may experience particular difficulties in taking time from work to attend for treatment. The author’s favourite quote from a patient was that ‘they don’t make old bones in my family!’. A collection of interactive medical and surgical clinical case scenarios to put your diagnostic and management skills to the test. Patients should be observed from the moment they enter the consulting room. In general, patients who are unwell are not good candidates for invasive procedures or treatments that are likely to demand close compliance on their behalf. patient’s medical history, inappropriate or unsafe treatment may be provided. MI is a gross necrosis of the myocardium due to interruption of the blood supply to the area. Medical Summary Reports. Injuries may often appear to be unrelated to the patient’s presenting complaint but it must be remembered that the lower limb functions as one unit and if one component of the unit is damaged, it can lead to compensations elsewhere in the lower limb. Registered users can save articles, searches, and manage email alerts. Diseases of nerves, muscle, bone and joints may be manifested by a patient’s gait or posture. ThedaCare Palliative Medicine Service, Theda Clark Medical Center, Neenah, Wisconsin. If the exposure to the allergen is systemic, hypotension, bronchiole constriction, laryngeal oedema, swelling of the tongue, urticaria, vomiting and diarrhoea may follow. The diagnosis in a patient presenting with difficulty walking will be influenced by a positive family history of a condition such as these. A patient’s medical history may include details about past diseases, illnesses running in the family, previous diagnoses, medical abstract, therapies, allergies, and medication. For example, aspirin and non-steroidal anti-inflammatory drugs (NSAIDs) may precipitate asthma attacks. In such circumstances oxygen must be administered to support the patient. The patient’s facial appearance and expression is also of interest to the practitioner. The questionnaire also covers details about the respondent’s schooling, family history, employment and medical history. H-LABOR is a daily email-based discussion group formed in 1993 that reaches over a … The approach outlined in this chapter forms the basis of a holistic approach to patient care. We must role-model how to take a social history for our trainees and peers. Diagnosis: A tropical parasitic infection with the jigger or sand flea, Tunga penetrans. But if the practitioner finds there is also a history of cigarette smoking, use of the contraceptive pill and recent immobilisation, the differential diagnosis would include deep vein thrombosis, a potentially life-threatening condition that requires quite different management to a pulled muscle. Refer to the British National Formulary (BNF) or another pharmacological text if you are unfamiliar with any drugs that the patient is taking. The pain was on the anteromedial aspect of the plantar heel pad and had been present for some time. The patient was subsequently prescribed stretching exercises and cortisone injections. One approach in refocusing on a patient-centered medical interview is to obtain the history in reverse of a standardized form (Table 1) and begin with the social history followed by the family history, medications, allergies, past medical history, and history of present illness (Table 2). Box 5.1 The medical history and systems enquiry. Syncope (fainting) is a transient loss of consciousness. A pedigree chart may be used to record details of major illnesses and lower limb problems of the immediate family (Fig. It can also be of value to record the cause of death of immediate family. Format of the medical and social history enquiry. This information will help to determine the inherited nature of any foot condition and, in the case of pes cavus, hallux valgus and lesser digit deformity, could indicate the degree of severity that the patient’s presenting condition may eventually achieve. Point tenderness at the origin of the medial band of the plantar fascia was elicited. For more information, please refer to our Privacy Policy. Past medical, family, and social history (PFSH) A chief complaint is required for all levels of charting. Example of a Complete History and Physical Write-up Patient Name: Unit No: Location: Informant: patient, who is reliable, and old CPMC chart. Other less-specific systemic cardiac. Diseases of nerves, muscle, bone and joints may be manifested by a patient’s gait or posture. It is characterised by inflammatory lesions of connective tissue structures, especially of the heart and blood vessels, and predisposes to bacterial endocarditis. The differential diagnosis includes MI, angina pectoris, pneumonia, pericarditis and oesophageal reflux. Most drugs produce several effects, but the prescriber usually wants a patient to experience only one (or a few) of them; the other effects may be regarded as undesired. A fertilised female, gaining access to human skin, burrows beneath the surface where it becomes engorged with blood.