Posted: September 13th, 2017

patient history tanking

patient history tanking

HISTORY TAKING ASSIGNMENT
Component 1: describe the role and meaning of the patient history taking interview and how it guides the examination process.
History taking is the first and most vital procedure that is undertaken when a new patient walks into the practitioners’ treatment room. It is presented in the form of an interview whereby the practitioner asks the patient relevant questions that aid in receiving valuable diagnostic information.
The history taking interview possesses a number of important roles. The practitioner is required to have extensive knowledge to obtain information that is needed, elicit correct and detailed information, and most importantly establish a rapport with the patient. It is incredibly vital for the practitioner to have a friendly and empathetic demeanor so that the patient feels comfortable sharing their personal information. These interpersonal skills help to set the scene between the practitioner and the patient for the remainder of the treatment process.
The history taking process gives a great deal of meaning to the patients’ chief complaint. Meaning is established by asking a series of questions that address all aspects of the patient, including their past, family, medical and social history, and also more directed questions that focus on their body systems. To gain a deeper understanding of the severity of the patients’ symptoms/complaint, yellow and red flagged questions may be asked. These questions allow for further meaning to be added in the patients’ history, aiding the differential diagnoses.
In order to gather this information the practitioner must start off with asking open ended questions that facilitate the patient in sharing their story. It is essential for the practitioner to constantly show interest and engage in eye contact with the patient at all times. It is also important not to interrupt the patient whilst they are talking as they might be giving you key information to aid your differential diagnosis.
Giving the patient your undivided attention really helps to guide the examination process. By listening you are able to pick up important information. This information can be readdressed in more detail by using close ended questions, and more specific leading questions. These types of questions should only be used once the patient has finished their story, to avoid the patient from getting confused or forgetting what they came to tell you. By facilitating the patient, the practitioner will be able to generate a number of hypotheses about the presenting complaint of the patient.

Component 2:
?    A 56 year old male butcher with bilateral swelling of the legs of 6 months duration.
Differential diagnosis:
–    Congestive cardiac failure
–    Liver disease
–    Standing for too long

–    To help differentiate the congestive heart failure differential diagnosis, emphasis will need to be placed on the patients’ family and past history, as well as specific questions to do with the cardiac system.
•    Review of the system – “Do you have any pain on walking or exercise? Does it get better with rest?” positive response to these are indicative of congestive heart failure. As the heart starts to fail it causes a decrease in CO ? increase in systemic venous pressure ? increase in hydrostatic pressure in the capillaries ? peripheral oedema
•    Family history – “Have your parents or grandparents ever had any heart problems?”
•    Next is to ask questions about their past history; e.g. “Have you had any previous history of a stroke or other heart conditions?” “Have you had this problem before?”

–    To distinguish if the bilateral peripheral oedema is being caused from liver failure, specific questions about the liver will need to be asked as well as touching on the patients past and family history.
•    “Have you noticed any changes to your skin colour recently or any changes to your hands?” “Have you noticed a change to the area around your breast tissue, has it enlarged at all?” Jaundice, palmer erythema, clubbing and gynaecomastia are all signs of liver disease.
•    Past history and system review, “Have you had this problem before?” “Do you have a history of high cholesterol level, how long ago has it last been checked?”. High cholesterol levels are due to impaired fat metabolism that may cause oedema.
•    “Have any of your family members had liver disease?”, for family history.
Severe cirrhosis of the liver will cause the patient to have low albumin and other protein levels. This will lead to the retention of fluid, causing it to leak into the extravascular spaces producing oedema in the legs of the patient.
–    To investigate whether the bilateral leg oedema is caused by standing for prolonged periods of time the patient will need to be asked specific questions about their job and work environment. This might be an option if the other serious conditions are all negative findings.
•    How long have you been working as a butcher, and how long are your work hours on a daily basis?
•    Are you standing the whole time in a stationary position, or are you moving around?
•    Does the swelling decrease when you sit or lie down, then worsen on standing again?
•    Have you been experiencing a problem with your weight recently?

?    A 42 year old female executive with chest pain (points to the area of the left 5th costochondral junction) of 3 days duration.
Differential diagnosis:
–    Angina
–    Costochondritis
–    Fracture

–    To differentiate for angina the following features will need to be questioned in the history:
Is the pain tight, squeezing, crushing or an ache?”
Does the pain radiate to the shoulder, down the arm, or to your neck?
Is the chest pain precipitated by activities of daily living such as effort, food, or emotion?
Is your chest pain relieved by rest?
Are you aware of any heart problems in your family?

–    Costochondritis differentiating questions:
Is the pain worse when you take a deep breath in or cough?
Have you recently had any infections or episode of severe coughing?

–    Fracture of the rib
Have you had any recent chest injuries?
Have you been diagnosed with any other medical conditions? Pathological problems such as osteoporosis may cause weakening of the bone leading to easier fracture.

Component 3
The special population that is of particular interest to me is adolescents. This is due the dynamic changes they experience as they branch from childhood into adulthood. Particular changes include the size and shape of their body, their interests, lifestyle factors and changes to their health. The areas of the history taking procedure that will be addressed with more emphasis are, current complaint, personal history, social history, medical history and a systems review.

Current complaint
It is always important to ask about the persons present compliant in detail when they first come into your clinic. Even though they may have had other issues in the past, knowing the location, intensity, duration, occurrence, and type of pain or discomfort the individual is experiencing is relevant for the path of your differential diagnosis. The adolescent’s current manifestations may or may not be correlating to other medical problems that they may have. That is why it is important to focus on the problem that they currently have, then later on whilst testing the patient, consider whether it may be connected to other problematic issues.

Personal history
Asking a young person about their personal history may be daunting and fearful for them. They may have experiences that they are hesitant to share with the practitioner that may be of good help. The importance of the personal history enables the practitioner to capture the personality of the individual. It also gives an insight to their life experiences, stressors, support systems and coping styles. It is important to ask about any verbal/physical abuse, observe the size and shape of their body, study habits and occupation. Trouble in these areas of their personal lives may lead to symptoms of depression or anxiety, having major effects on all aspects of their daily living and health.

Social history
The importance of a social history is that it helps in understanding any risk factors that may be essential in producing a differential diagnosis for the adolescent. Areas of their social lives that should be noted are their sporting hobbies, and the use of alcohol/recreational drugs. These may all be important factors that are contributing to their current complaint.
–    Being socially and physically active is important for both the health and mood of the young adult. Research shows that exercise has positive effects on obesity in young adults. Controlling the rate of obesity whilst young will have beneficial effects on other aspects of health as they become adults.  Playing sports also gives them the opportunity to meet new people and improve their social skills.
–    It is also of importance to know if the adolescent uses any recreational drugs or drinks alcohol. If they are under the influence of these it may have negative effects on the treatment process. It is vital to know how much they have and how often they do it.

Medical history
It is essential to take a past and present medical history of the patient. This allows the practitioner to know about any medications the young adult might be on, any childhood diseases they have had, their vaccination history, previous surgery/fractures, and insight on whether they may have congenital anomalies. Knowing this information is essential as the patient may need to be contraindicated to certain or all spinal manipulative therapy.

Systems review
This section is of great importance as it helps to uncover other symptoms that may have been overlooked in the other section of the interview. It helps to differentiate between the body systems and draws attention to any underlying causes of the present complaint of the individual. It is vital to go through each system individually for a better diagnosis of the causative agent.
A few examples of systems to review include:
Respiratory: 5% of adolescents complain about having chest pain.
–    The practitioner needs to be able to differentiate between musculoskeletal, inflammatory problems, trauma, and pulmonary causes of pain.
?    Symptoms become of concern when the chest pain is precipitated by exercise, disrupts sleep, or causes difficulty with breathing and palpitations in the young individuals. 9
Headaches: 75% of 15 year olds have experienced recurrent headaches, although most of which are not associated with severe pathology. The causative agent of the headache is really important to know. They may be due to stress, anxiety, or related to diet and lifestyle factors. The patient may also have eye problems and have glasses on which may be a cause of the headaches if other causes are negative. 9
–    It is of great importance to know about the onset of the pain, frequency, severity, and aggravating/relieving factors to help with the diagnosis of the headache.

Fatigue: The feeling of being fatigue is also common amongst young adults. This symptom is generalized so it is important to get a full understanding as to what the underlying cause of the fatigue is.
–    If red flags such as night sweats, unexplained weight loss, or fever are present then the fatigue may be a cause of systemic diseases and will need further investigation.
Abdominal pain: This is also a generalized symptom having many causes. It is important to differentiate between referred pain from other organs, and also look for guarding, rebound tenderness or masses in the area of concern.