It is characterised by inflammatory lesions of connective tissue structures, especially of the heart and blood vessels, and predisposes to bacterial endocarditis. Have you been off work due to illness for more than 1 week in the past 6 months? This may manifest clinically as vertebral collapse, leading to spinal. • need an Eye opener drink needed in the morning. For immediate assistance, contact Customer Service: The systems enquiry may reveal significant symptomatology which the practitioner is either inexperienced in or unqualified to diagnose. An inadequate history of the patient’s health status may have the following consequences: With an inadequate knowledge of the patient’s medical history, inappropriate or unsafe treatment may be provided. Medical and Health Professions; ... and employment history. Of particular concern to the podiatric practitioner is the potential for overdosage of local anaesthetics, which can lead to convulsions as a result of central nervous system depression. 1 Verghese A. Did you have any major childhood illnesses? symptoms include fatigue and decreased exertional tolerance. “My dog becomes visibly agitated and starts barking after smelling my breath when I'm getting sick,” she offered quickly when asked. It is the least expensive of all investigations and time spent on obtaining a thorough history is rarely wasted. Get new journal Tables of Contents sent right to your email inbox, Articles in PubMed by Ruric (Andy) Anderson, MD, MBA, Articles in Google Scholar by Ruric (Andy) Anderson, MD, MBA, Other articles in this journal by Ruric (Andy) Anderson, MD, MBA, by the Association of American Medical Colleges. What do you smoke – cigarettes, cigars, a pipe? Data is temporarily unavailable. Inadequate history taking may place the practitioner at risk when handling tissue fluids or products. Ask the patient if they: The most important cardiovascular symptom to elicit is chest pain (Table 5.2) because of the range of pathologies responsible for its occurrence. Enquiry about the medical history of the immediate family may reveal a predisposition to a range of systemic diseases, a good example of which is non-insulin-dependent diabetes. Once a history has been taken, physical examination and diagnostic tests can then be used to confirm the diagnosis and stage the severity of the condition. More than four units of alcohol per day is noteworthy. Social History (SH): This is a broad category which includes: Alcohol Intake: Specify the type, quantity, frequency and duration. 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). 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. The social history in a medical history report needs to add if the patient has any sort of tobacco, alcohol or caffeine addiction. Chief complaint (CC) 2. Hospitalisations for operations or injuries should be recorded and any complications noted (Case history 5.1). 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. Alcohol consumption is generally measured in units. The diagnosis in a patient presenting with difficulty walking will be influenced by a positive family history of a condition such as these. It seeks to discover if the patient has any systemic conditions, particularly those that may affect the patient’s lower limb problem, and to unearth any signs and symptoms which the patient has not complained of spontaneously. It mobilises popular enthusiasm and engages popular passions. Poor history taking may result in a request for an inappropriate antibiotic prescription from a general practitioner for a patient who is sensitive to penicillin. Cyanotic blue lips are a sign of poor cardiac function. Pulmonary oedema and shortness of breath are, therefore, signs and symptoms of left-sided heart failure. Patients with chronic foot disorders may shuffle rather than stride because a propulsive gait could cause more pain. “Building” a history rather than “taking” one: A perspective on information sharing during the medical interview. When it does occur it usually follows entry of an antigenic drug into the circulation of a sensitised individual. This includes his or her age, gender, race, height, weight, current residential address and previous addresses. It can also be of value to record the cause of death of immediate family. It is important to consider the patient’s home situation. 2008;359:2748–2751. However, these patients are often more prone to injury because they are often not as fit and do not follow appropriate warm-up and warm-down regimens. 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. And it should also involve the marital and living status of the patient. Patients with chronic foot disorders may shuffle rather than stride because a propulsive gait could cause more pain. MEDICAL HISTORY Pregnancy: Please describe any complications, medications taken, or other concerns experienced during pregnancy (e.g., high blood pressure, toxemia, gestational diabetes, etc.) If drugs are prescribed (or omitted) in the absence of a detailed medical history, an existing condition may be exacerbated. To compensate for this, first the heart rate and then the volume of blood filling the left ventricle increases. Information about the patient’s previous and current drug therapy can provide useful information about the patient’s health. Patients should be asked if they are currently taking, or have taken in the past, any tablets or other medicines, or if they are using or have used any ointments or creams prescribed by their doctor. History, social: An account of a patient that puts his or her illness or behavior in context. Acromegaly, in which there is an excess of growth hormone production due to a disorder of the pituitary gland, will give rise to a heavy ‘lantern’ jaw. Consistent with a call from the Institute of Medicine to better incorporate social and behavioral sciences into medical training, 2 we suggest that the primary tool that identifies the social circumstances of the patients, the social history, be revisited. The varied needs of older patients may require different interviewing techniques. 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. For a new patient or consult, the clinician might say, "The past medical history shows that she has longstanding hyperllipidemia. Arch Intern Med. Example of a Complete History and Physical Write-up Patient Name: Unit No: Location: Informant: patient, who is reliable, and old CPMC chart. The site of penetration is usually found under the toe nail of the barefooted patient, but can occur on the plantar aspect of the foot. All these factors have implications for cost and litigation. 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. Many cardiovascular, alimentary, neurological and endocrine disorders can be inherited and therefore the use of pedigree charts is particularly useful in paediatrics. 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. Comprehensive The lowest common history level met by all elements determines the highest billable E… For information on cookies and how you can disable them visit our Privacy and Cookie Policy. Format of the medical and social history enquiry 3. 30 mins. Are you exposed to passive smoking at home? Originally a native of the New World, it is now widely disseminated in Africa and Asia. In the drive for efficiency and reliance on technology, the connection between patient and doctor need not be lost.1 We should aim to at least equal good hairstylists, who keep track of personal details on cards or in memory so they can make connections with their clients. The patient’s facial appearance and expression is also of interest to the practitioner. 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. to maintaining your privacy and will not share your personal information without 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. Table 5.1 Adverse effects of drugs affecting the lower limb. The use of questionnaires gives patients time to consider their answers and reduces the time spent in taking a medical history during the consultation. a thrombosis or blood clot (deep vein thrombosis [DVT]), Angiotensin-converting enzyme (ACE) inhibitors, Central, crushing pain that radiates into the arms and jaw. Introduction 2. A history of jaundice should alert the practitioner to the possibility of hepatitis, whereas a history of haemophilia, blood transfusion, foreign travel or intravenous drug use may place the patient – and thus the practitioner – at risk from a blood-borne infection. Certain lower limb pathologies can be inherited or seem to have a familial predisposition, especially diseases that are neurological in nature such as Friedreich’s ataxia and Charcot–Marie–Tooth disease. Before history taking begins, the practitioner will gain some impressions about the patient’s current health status from simple observation. Format of the medical and social history enquiry. In such circumstances oxygen must be administered to support the patient. For some of the time in India he walked around barefoot and recalls occasionally having to remove splinters and small stones from his sole. For example, a problem-focused history requires documentation of the chief complaint (CC) and a brief history of present illness (HPI), while a detailed history requires the documentation of a CC, an extended HPI, plus an extended review of systems (ROS) and pertinent past, family and/or social history … 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. 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. He presented with a pruritic, inflamed lesion with a central black dot, under the free edge of the hallucal toe nail of his left foot. 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. A 27-year-old female sales executive attended the clinic with heel pain. Some error has occurred while processing your request. Your message has been successfully sent to your colleague. Patients should be observed from the moment they enter the consulting room. 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 65-year-old woman attended the podiatry clinic complaining of weak muscles in her legs. These patients are more likely to develop hamstring or calf muscle injury due to poor flexibility – the so-called weekend warrior. “So how is your son doing in college?” “Did you plant a garden again this year?”. Wasting of the thenar eminence and intrinsic musculature of the hand occurs with rheumatoid arthritis and with some genetic disorders such as Friedreich’s ataxia and Charcot–Marie–Tooth disease. Conventions exist regarding the symbols used in the charts. Diseases of nerves, muscle, bone and joints may be manifested by a patient’s gait or posture. History taking is as important as any diagnostic test or physical examination. Rheumatic fever is a febrile disease occurring as a sequel to group A haemolytic streptococcal infections. following an MI patient cannot drive for one month. Summary 5. • Have you ever been under the care of a consultant or a hospital specialist? In some individuals, contact with certain allergens will stimulate the production of an antibody of the immunoglobulin E (IgE) class, which has the ability to adhere to mast cells in tissues and basophils in the circulation. penicillin) should be sought and explored. N Engl J Med. 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. This causes immediate destruction of the mast cell, which releases its contents, specifically histamine, serotonin, platelet-activating factor and slow-reacting substance. Cf Family history. 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. Patients who participate in infrequent sporting activities may not think of informing the practitioner of these activities. For more information, please refer to our Privacy Policy. 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. 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’. The patient was subsequently prescribed stretching exercises and cortisone injections. The ethnic origin of the patient should also be noted. The patient should then be asked: • Have you been off work due to illness for more than 1 week in the past 6 months? MI is a gross necrosis of the myocardium due to interruption of the blood supply to the area. Unfortunately, it is likely that those patients misusing alcohol are least likely to be forthcoming about their alcoholism. A type I hypersensitivity reaction, which may lead to anaphylactic shock, is of most concern. A properly taken medical and social history is concerned with the patient as a whole and not just the lower limb complaint with which the patient has presented. iodine allergy) or dressings (e.g. Family Medical History Form is a format that captures the Medical History of family pertaining to ailments which are hereditary in nature. This will help the Doctors to decide on the course of treatment. Anderson, Ruric (Andy) MD, MBA; Schiedermayer, David MD, Assistant dean for medical education, NorthShore University HealthSystem, and clinical associate professor of medicine, University of Chicago Pritzker School of Medicine, Evanston, Illinois; [email protected]. The clinician must therefore be… Weight abnormalities affect the lower limb and should be noted on the first meeting with the patient. Each clinical case scenario allows you to work through history taking, investigations, diagnosis and management. 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. Have you ever been under the care of a consultant or a hospital specialist? Insect stings are also an important cause of anaphylactic fatality. Cardiac disease such as arrhythmias and aortic stenosis can cause syncope by decreasing the cerebral blood supply. 4. 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). Step 4: Women’s Health History 5.1). Examination revealed a hyperpronatory foot type. For example, pain and swelling in the calf of a 39-year-old woman, which develops after sport, may be nothing more than local oedema or muscle strain. These questions will hopefully prompt the patient into recollecting any previous incidents of illness or surgery. 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). The differential diagnosis includes MI, angina pectoris, pneumonia, pericarditis and oesophageal reflux. A 23-year-old secretary presented with pain in the first metatarsophalangeal joint. The following questions will reveal important information about the patient’s general health: • Are you under the doctor or consultant for any treatment currently? Drinking before 10 a.m. is an important finding as it is associated with chronic alcoholism. Patients should be observed from the moment they enter the consulting room. Hypertension is a risk factor for many life-threatening conditions such as MI, renal failure and cerebral vascular accidents (strokes). In such cases the skin around the area of the injection shows an immediate, localised inflammatory reaction. Bare concrete floors will exacerbate chilblains, whereas patients whose occupation involves standing on ladders will often suffer from chronic medial longitudinal arch pain. Information about the patient’s previous and current drug therapy can provide useful information about the patient’s health. It publishes International Labor and Working-Class History. Although most people use the term ‘side effect’, the term ‘adverse drug reaction’ is more appropriate for effects that are undesired, unpleasant, noxious or potentially harmful. A 23-year-old man attended clinic after 6 months of working as a volunteer in India. Where alcohol misuse is suspected, questions should be asked in a permissive manner. Inadequate knowledge of the patient’s existing medication could lead to adverse inter-drug reactions with newly prescribed treatment. 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. Lippincott Journals Subscribers, use your username or email along with your password to log in. 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. Ask if they: • have Cut down on drinking – have tried repeatedly without success, • are Annoyed by criticism about drinking habits. Causes include valvular heart disease, myocardial disease and hypertension (Case history 5.4). A comprehensive history taking therefore initiates the diagnostic process and helps the practitioner to formulate and implement an effective management plan. Are you under the doctor or consultant for any treatment currently? How can we physicians change the culture of our institutions to promote the taking of a proper social history? Adequate history taking will identify those patients who have previously developed adverse reactions. The consultation should begin with a handshake as considerable information can be gleaned from this simple contact. Social History Assessment is the first resource to offer practical guidance about interpreting the social history. A fertilised female, gaining access to human skin, burrows beneath the surface where it becomes engorged with blood. 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. _____ Birth/ Delivery: Was the child full term? Remember to ask about smoking and alcohol. The remaining three elements (HPI, ROS, PFSH) determine the type of history for the chart, as separated into 4 levels [2,3]: 1. 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. Diagnosis: Traumatic arthritis. Your account has been temporarily locked due to incorrect sign in attempts and will be automatically unlocked in The updated Social history section on the patient Summary includes improvements to smoking status, which has been renamed “Tobacco Use”, and additional data elements to support recording alcohol use, financial resources, education, physical activity, stress, social isolation and connection, and exposure to violence.You can also find free text fields for Nutrition and Social history … The first meeting of the Society for the Social History of Medicine (8 May 1970) heard a lecture by Thomas McKeown entitled ‘A sociological approach to the history of medicine’. In females, a particularly common procedure is hysterectomy, which has implications for the lower limb in that the effect on hormone balance can lead to premature osteoporosis. Amphetamines, like many mood stimulants, have a vasoconstrictive effect. One unit of alcohol is equivalent to one glass of wine, a single measure of spirits or half a pint of beer. Expanded Problem Focused 3. Small plaques of brown lipid under the eyes, seen in hyperlipidaemia, are associated with atherosclerosis. Ask if the visit was urban or rural and whether they had any specific vaccinations. “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. Seriously underweight patients may have a range of systemic conditions or they could be poorly nourished due to alcoholism, drug misuse or anorexia nervosa. Patients on long-term steroid therapy can develop a ‘moon’ face. 2 Haidet P, Paterniti DA. The actual risk of causing a bacteraemia in a patient with a prosthetic joint (which could infect and then loosen the joint) by performing nail surgery remains unquantified but a theoretical risk certainly exists. It touches on, and arguably helps to focus, major issues of public debate, as for example on British national character or the nature of family life. Arrhythmias may present as bradycardia (slow heartbeat) or tachycardia (fast heartbeat) with varying degrees of irregularity. The range of motion of the joint was reduced, with painful crepitus evident on dorsiflexion. Cigarette smoking: Determine the number of packs smoked per day and the number of years this has occurred. 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. Please try after some time. The history includes 4 elements: 1. Registered users can save articles, searches, and manage email alerts. For example, repeatedly exceeding the recommended daily dosage of vitamins A and D supplements may. Gravity will force most of the transudate to collect bilaterally in the feet and ankles. Sitting down relieved the pain but prolonged sitting tended to make her ankles swell. Point tenderness at the origin of the medial band of the plantar fascia was elicited. Problem Focused 2. Use of recreational drugs should be recorded. An increase in blood pressure is often asymptomatic and many hypertensive people do not realise they have the condition until they develop symptoms (e.g. 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. All registration fields are required. 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. Syncope (fainting) is a transient loss of consciousness. Fatigue and weight changes are symptoms of many systemic illnesses and are always worthy of note, especially if weight change seems to be rapid. 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. 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. Physicians can and must do better. A social history questionnaire seeks to provide details about a person’s social history. The patient should be asked if anyone else in the family has suffered from leg or foot problems. An illustrative poem or short work of literature can be incorporated into morning report or teaching rounds. Diagnosis: Plantar fasciitis. Lack of home support may rule out certain forms of treatment. If drugs are prescribed (or omitted) in the absence of a detailed medical history, an existing condition may be exacerbated. If the exposure to the allergen is systemic, hypotension, bronchiole constriction, laryngeal oedema, swelling of the tongue, urticaria, vomiting and diarrhoea may follow. This may be followed by a profound drop in blood pressure and life-threatening cardiovascular depression. 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. For one patient with COPD who came to the emergency department, the social history, with a simple question about pets, revealed crucial data. • Have you ever been admitted to hospital? Certain rhythms such as ventricular tachycardia predispose to cardiac arrest. 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. 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… 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). Information gleaned from a skilled enquiry is the first step towards making the correct diagnosis, directing further investigations and facilitating the formulation of an appropriate treatment plan. Medication history: now and past, prescribed and over-the-counter medicines, allergies. An X-ray revealed a compression fracture to the head of the first metatarsal, which has predisposed degeneration of the joint. See Psychiatric history. Patients with. 2. Thalassaemia, another haemolytic anaemia, can affect patients from the Mediterranean and Southeast Asia. This condition can have a direct effect on the ability of the muscles to function under strain. This can be sent to the patient before the initial visit or, more commonly, before they see the practitioner again. The subsequent referral for a second opinion should be seen as part of the patient’s overall treatment plan. For example, prednisolone, commonly used in the treatment of rheumatoid arthritis, can reduce skin thickness and impair wound healing. 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. However, the patient was required to wear fashionable court shoes for her employment. 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. 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. Examples of how to use “social history” in a sentence from the Cambridge Dictionary Labs In females, a particularly common procedure is hysterectomy, which has implications for the lower limb in that the effect on hormone balance can lead to premature osteoporosis. A patient’s medical history may include details about past diseases, illnesses running in the family, previous diagnoses, medical abstract, therapies, allergies, and medication. In CHF there is an inadequacy in the supply of oxygenated blood. (Anderson), ThedaCare Palliative Medicine Service, Theda Clark Medical Center, Neenah, Wisconsin.(Schiedermayer). The systems enquiry is the key part of the medical history. 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.