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- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Sprache: Englisch
A concise, quick-reference handbook on history taking and physical examination
Pocket Guide to Physical Assessment is a compact yet comprehensive reference for students and practitioners alike, employing a step-by-step framework for effective patient assessment, diagnosis and planning of care.
This valuable guide covers topics including cardiovascular, respiratory, neurological and musculoskeletal system examinations, patient interviews, history taking and general health assessments. Clear diagrams and checklists illustrate key points, while easy-to-follow instructions and concise descriptions of clinical situations and diseases aid in clinical decision-making.
- Compact, pocket-sized guide that contains only the essential information for physical assessment
- Instructs readers on best clinical practice and how to present and communicate cases
- Develops and improves necessary skills for physical clinical examinations
- Ideal for use on the ward or as a companion to the accompanying textbook, Physical Assessment for Nurses and Healthcare Professionals
Pocket Guide to Physical Assessment is an invaluable reference for healthcare students, newly qualified and advanced nurse practitioners, and allied health practitioners.
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Seitenzahl: 408
Veröffentlichungsjahr: 2019
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Table of Contents
Cover
List of Contributors
Foreword
Preface
Acknowledgements
1 Interviewing and History Taking
1.1 General Procedures
1.2 Functional Enquiry
1.3 Past History
1.4 Family History
1.5 Personal and Social History
References
2 General Health Assessment
2.1 Introduction
2.2 General Inspection
2.3 Hands
2.4 Skin
2.5 Mouth
2.6 Eyes
2.7 Examine the Fundi
2.8 Examine for Palpable Lymph Nodes
2.9 Lumps
2.10 Heart
2.11 Breasts
2.12 Respiratory
2.13 Thyroid
2.14 Other Endocrine Diseases
2.15 Abdomen
2.16 Musculoskeletal
References
3 Basic Examination, Notes, and Diagnostic Principles
3.1 Basic Examination
3.2 Example of Notes
3.3 Problem List and Diagnoses
References
4 Examination of the CardiovascularSystem
4.1 Introduction
4.2 General Examination
4.3 Palpate the Radial Pulse
4.4 Take the Blood Pressure (BP)
4.5 Jugular Venous Pulse (Frequently Called Pressure)
4.6 Musset’s Sign
4.7 The Precordium
4.8 Auscultation
4.9 Signs of Left and Right Ventricular Failure
4.10 Functional Result
4.11 Summary of Common Illnesses
4.12 Peripheral Arteries
4.13 Varicose Veins
4.14 System Orientated Examination
4.15 Reference Guide: Intracardiac Values and Pressures
References
5 Examination of the Respiratory System
5.1 Introduction
5.2 General Examination
5.3 Physical Assessment of the Chest
5.4 Inspection of the Chest
5.5 Palpation
5.6 Percussion
5.7 Auscultation
5.8 Vocal Fremitus/Resonance
5.9 Sputum
5.10 Functional Result
5.11 Summary of Common Illnesses
5.12 System‐Oriented Examination
References
6 Examination of the Abdomen
6.1 Introduction
6.2 General Examination
6.3 Abdominal Pain
6.4 Inspection
6.5 Auscultation
6.6 Palpation
6.7 Percussion
6.8 Examination of Genitals
6.9 Digital Rectum Examination
6.10 Per Vaginam Examination
6.11 Summary of Common Illnesses
References
7 Examination of the Male Genitalia
7.1 Introduction
7.2 General Examination
7.3 Inspection
7.4 Palpation
References
8 Examination of the Female Genitalia
8.1 General Examination
8.2 Preparation
8.3 Inspection of the External Genitalia
8.4 Speculum Examination (Figure 8.1)
8.5 Bimanual Examination
8.6 Documentation
8.7 Female Genital Mutilation
8.8 Overview of Common Presentations
References
9 Examination of the Nervous System
9.1 General Examination
9.2 General Examination
9.3 Motor and Sensory Function
9.4 Mental Function
9.5 Skull and Spine
9.6 Cranial Nerves (I–XII)
9.7 Limbs and Trunk
9.8 Lower Limbs
9.9 Summary of Common Illnesses
References
10 Examination of the Eye
10.1 General Examination
10.2 History Taking in the Ophthalmic Assessment
10.3 Allergies
10.4 Occupation
10.5 Examination
10.6 Recording Visual Fields
10.7 Testing the Child’s Vision
10.8 Ocular Examination of the Adult
10.9 Ocular Examination of the Child
10.10 Use of a Slit Lamp
10.11 Measurement of Intraocular Pressure
10.12 Palpation of the Globe
10.13 Use of an Ophthalmoscope
10.14 Pupil Assessment for Relative Afferent Papillary Defect (RAPD)
10.15 Documentation
References
11 Examination of the Musculoskeletal System
11.1 General Examination
11.2 Frequent Musculoskeletal Complaints
11.3 Key Principles of Musculoskeletal Assessment
11.4 Practical Considerations
11.5 Assessment Consideration
11.6 Legal Consideration
11.7 Inspection
11.8 Palpation
11.9 Range of Movement
11.10 Limb Measurement
11.11 Bones
11.12 Joints
11.13 Muscles
11.14 The Examination
11.15 Gait, Arms, Legs, Spine Screen
11.16 General Survey
11.17 Regional Examination
11.18 Muscle Strength Tests
11.19 Terms of Location
11.20 Terms Used to Describe ROM
11.21 Reference Grid for Examination
References
12 Presenting Cases and Communication
12.1 Presentations to Healthcare Professionals and Patients
12.2 People – Including Patients
References
Appendix A: Jaeger Reading Chart
Reference
Appendix B: Visual Acuity 3 Meter/21 Foot Chart
Reference
Appendix C: Hodkinson Ten‐Point Mental Test Score
Reference
Appendix D: Barthel Index of Activities of Daily Living
Guidelines for the Barthel Index of Activities of Daily Living (ADL)
Reference
Appendix E: Mini‐Mental State Examination (MMSE)
References
Appendix F: Glasgow Coma Scale
Reference
Appendix G: Warning Signs of Alzheimer’s Disease
Reference
Appendix H: Trigger Symptoms Indicative of Dementia
References
Appendix I: The 12‐Lead Electrocardiogram
I.1 General Principles
I.2 Normal ECG (Figure I.6)
I.3 Electrophysiology of Cardiac Contractions
I.4 QRS Axis
I.5 QRS Complex
I.6 Arrhythmias
I.7 Ectopics
I.8 Tachycardias
I.9 Bradycardias
I.10 Pacemakers
I.11 Looking at the ECG
Index
End User License Agreement
List of Tables
Chapter 2
Table 2.1 Distribution of components in the four imaginary quadrants of the a...
Chapter 4
Table 4.1 Intracardiac values and pressures.
Chapter 5
Table 5.1 Discrimination of sounds.
Table 5.2 Characteristics of sounds.
Chapter 8
Table 8.1 Materials needed for a pelvic examination.
Table 8.2 Differential diagnosis of acute pelvic pain.
Chapter 9
Table 9.1 The brain.
Table 9.2 Spinal nerves.
Table 9.3 SOCRATES.
Table 9.4 Glasgow Coma Scale (GCS).
Table 9.5 ‘Examine the cranial nerves’.
Appendix I
Table I.1 Classic time sequence of onset of electrocardiogram (ECG) changes i...
List of Illustrations
Chapter 1
Figure 1.1 Usual sequence of events.
Chapter 2
Figure 2.1 Nine abdominal quadrants and location of organs in epigastric, hyp...
Chapter 8
Figure 8.1 Speculum examination.
Figure 8.2 Bimanual examination.
Chapter 9
Figure 9.1 Visual Field Defects.
Chapter 10
Figure 10.1 The eye.
Appendix I
Figure I.1 The positioning of the limb electrodes and the six standard leads....
Figure I.2 Examining the vertical plane.
Figure I.3 Examining the horizontal plane.
Figure I.4 Coronary arteries.
Figure I.5 Standardising the electrocardiogram (ECG) tracing. P, atrial depol...
Figure I.6 A normal electrocardiogram (ECG).
Figure I.7 Conduction system (electrical pathway).
Figure I.8 Sinoatrial (SA) node P wave.
Figure I.9 QRS in the V leads.
Figure I.10 Depolarization of the septum.
Figure I.11 Depolarization of the ventricles.
Figure I.12 The transition point.
Figure I.13 Left ventricular hypertrophy.
Figure I.14 Left ventricular hypertrophy strain pattern.
Figure I.15 Right ventricular hypertrophy.
Figure I.16 Pathological Q wave.
Figure I.17 Normal baseline.
Figure I.18 Baseline changes in myocardial injury.
Figure I.19 Acute anterior infarct: ST ↑ V
2–6
at three to eight hours....
Figure I.20 Ten hours after anterior myocardial infarct.
Figure I.21 Acute inferior infarct: ST · in II, III, aVF with reciprocal depr...
Figure I.22 Chronic myocardial ischaemia.
Figure I.23 QRS axis.
Figure I.24 Left axis deviation.
Figure I.25 Right axis deviation.
Figure I.26 Left bundle branch block.
Figure I.27 Right bundle branch block.
Figure I.28 Sinus arrhythmia.
Figure I.29 Atrial ectopics.
Figure I.30 Junctional or nodal ectopics.
Figure I.31 Ventricular ectopics.
Figure I.32 Sinus tachycardia.
Figure I.33 Atrial fibrillation.
Figure I.34 Atrial flutter.
Figure I.35 Supraventricular tachycardia.
Figure I.36 The mechanism of re‐entry tachycardias.
Figure I.37 Wolff–Parkinson–White syndrome.
Figure I.38 Ventricular tachycardia.
Figure I.39 Sinus bradycardia.
Figure I.40 Sinus arrest with vagal stimulation.
Figure I.41 First‐degree heart block.
Figure I.42 Wenckebach heart block.
Figure I.43 2 : 1 block.
Figure I.44 Complete heart block.
Figure I.45 Ventricle pacemakers.
Figure I.46 Sequential pacing.
Guide
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Table of Contents
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Pocket Guide to Physical Assessment
Edited by
Carol Lynn Cox
PhD, MSc, MA (Theology), MA (Education), PG Dip Education, BSc (Hons), RN, ENB 254, FHEA
Professor Emeritus, School of Health Sciences, City, University of London, London, UK and Clinical Manager and Director of Nursing, Health and Hope Clinics, Pensacola, FL, USA
Adapted from Lecture Notes on Clinical Skills (Third Edition) by:
The late Robert Turner MD, FRCP
Professor of Medicine and Honorary Consultant Physician
Nuffield Department of Clinical Medicine
Radcliffe Infirmary, Oxford, UK
Roger Blackwood MA, FRCP
Consultant Physician, Wexham Park Hospital, Slough, and Honorary Consultant Physician at Hammersmith Hospital, London, UK
This edition first published 2019 © 2019 by John Wiley & Sons Ltd
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by law. Advice on how to obtain permission to reuse material from this title is available at http://www.wiley.com/go/permissions.
The right of Carol Lynn Cox to be identified as the author of editorial in this work has been asserted in accordance with law.
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Limit of Liability/Disclaimer of WarrantyThe contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting scientific method, diagnosis, or treatment by physicians for any particular patient. In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions. While the publisher and authors have used their best efforts in preparing this work, they make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of merchantability or fitness for a particular purpose. No warranty may be created or extended by sales representatives, written sales materials or promotional statements for this work. The fact that an organization, website, or product is referred to in this work as a citation and/or potential source of further information does not mean that the publisher and authors endorse the information or services the organization, website, or product may provide or recommendations it may make. This work is sold with the understanding that the publisher is not engaged in rendering professional services. The advice and strategies contained herein may not be suitable for your situation. You should consult with a specialist where appropriate. Further, readers should be aware that websites listed in this work may have changed or disappeared between when this work was written and when it is read. Neither the publisher nor authors shall be liable for any loss of profit or any other commercial damages, including but not limited to special, incidental, consequential, or other damages.
Library of Congress Cataloging‐in‐Publication DataNames: Cox, Carol Lynn, editor. | Adaptation of (expression): Turner, Robert, 1938–1999. Lecture notes on clinical skills. 3rd edition.Title: Pocket guide to physical assessment / edited by Carol Lynn Cox.Description: Hoboken, NJ : Wiley‐Blackwell, 2019. | Adapted from Lecture notes on clinical skills / Robert Turner, Roger Blackwood. 3rd ed. 1997. | Includes bibliographical references and index. |Identifiers: LCCN 2019003275 (print) | LCCN 2019004179 (ebook) | ISBN 9781119108931 (Adobe PDF) | ISBN 9781119108948 (ePub) | ISBN 9781119108924 (pbk.)Subjects: | MESH: Physical Examination–methods | Diagnostic Techniques and Procedures | HandbookClassification: LCC RC78.7.D53 (ebook) | LCC RC78.7.D53 (print) | NLM WB 39 | DDC 616.07/54–dc23LC record available at https://lccn.loc.gov/2019003275
Cover Design: WileyCover Images: © George Doyle/Getty Images, © Seth Joel/Getty Images, © Jeffrey Coolidge/Getty Images, © kokouu/Getty Images
List of Contributors
Graham M. Boswell, DEd, MA Ed, BA (Hons), BSc (Hons) RGN, FHEASenior Lecturer, Department of Adult Nursing and Paramedic Science, Faculty of Education and Health, University of Greenwich, London, UK
Carol Lynn Cox, PhD, MSc, MA (Theology), MA (Education), PG Dip Education, BSc (Hons), RN, ENB 254, FHEAProfessor Emeritus, School of Health Sciences, City, University of London, London, UK and Clinical Manager and Director of Nursing, Health and Hope Clinics, Pensacola, FL, USA
Helen Gibbons MSc, PG Cert (Medical Education), ENB (Ophthalmic Practice), BA (Hons), RNClinical Nursing Lead (Education and Research), Moorfields Eye Hospital NHS Foundation Trust and Course Director, University College London, London, UK
Victoria Lack, MSN, PG Dip (Academic Practice), BN (Hons), Family Nurse Practitioner, Non‐Medical Prescriber, DN (Cert), RNLecturer in Primary Care, Department of Health Sciences, University of York, York, UK, and Advanced Nurse Practitioner, Beech House Surgery, Knaresborough, North Yorkshire, UK
Anthony McGrath, PhD, MSc, PGCE, BA (Hons) RMN, RGN, FHEAPrincipal Lecturer, Head of Adult Nursing and Midwifery, London South Bank University, London, UK
Nicola L. Whiteing, PhD, MSc, PG Dip HE, BSc (Hons), RN, RNT, ANPLecturer in Nursing, Southern Cross University, New South Wales, Australia
Foreword
Underpinning the appropriate delivery of healthcare is the Physical Assessment. This structured physical examination allows the healthcare professional to obtain a comprehensive assessment of the patient and is critically important in that it leads to clinical decisions that are crucial for the patients' care.
This Pocket Book, Pocket Guide to Physical Assessment, provides a clear and easy‐to‐use reference guide for achieving the Physical Assessment. It is specifically intended for those embarking on a career in healthcare and contains the techniques used by specialist/advanced practitioners.
In this Pocket Guide, the need for a thorough approach to the Physical Assessment is excellently presented by Professor Cox. Professor Cox shows how important it is to develop a rapport with the patient in order to carefully assess their perceptions and how this relationship must be established from the very first meeting when information is exchanged between the healthcare professional and the patient. Fundamental to gaining this perspective is to listen. The importance of guiding the healthcare practitioner to engage in active listening cannot be underestimated and this is reflected in the fact that not being heard is an issue that is often raised as a point of criticism of healthcare professionals by patients and their families.
Careful observation and reports of subjective symptoms are the window through which healthcare professionals gain knowledge of their patients. Following the opening chapters, this Pocket Guide is structured to enable the healthcare professional to learn how to systematically gather information before moving on to an initial diagnosis and further investigations. The tools of inspection, palpation, percussion, and auscultation are key to this assessment and are excellently laid out in the chapters covering the examination of the different organs of the body.
It is key for healthcare professionals to be able to communicate the outcomes of their Physical Assessment to their professional colleagues. Professor Cox demonstrates her experience and understanding of the world of healthcare when she talks about the importance of this communication between professionals and how the Physical Assessment can bring together the disparate professional views that will underpin the diagnostic process.
In this Pocket Guide to Physical Assessment, Professor Cox has created an invaluable guide that will not only support practitioners as they begin a clinical career in healthcare but will also function as an ongoing reference book to support their careers.
Professor Stanton Newman, Pro Vice Chancellor Research, City University London, England, UK
Preface
Over the past decade many changes have occurred in relation to medical practice. What has not changed, and should not change, is the view healthcare professionals have in relation to the patient. This view sees the patient as an individual with physical as well as emotional, psychological, intellectual, social, cultural, and spiritual needs. A comprehensive assessment of the patient is the foundation upon which healthcare decisions are made. The best way to develop assessment skills is to learn them systematically. The systematic approach involves taking a full health history, physical examination, and reviewing diagnostic texts/laboratory data. Use of a systematic approach is essential in clinical decision making, which leads to the formulation of a differential diagnosis and final diagnosis.
This Pocket Guide for healthcare professionals is based on Robert Turner’s and Roger Blackwood’s Lecture Notes on Clincal Skills that was written for medical students and Carol Cox’s Physical Assessment for Nurses. It is intended to be used as a guide when examining patients in the clinical setting. The Guide includes simple instructions on examination approaches and details of diseases that are relevant to abnormal findings.
Turner and Blackwood's Lecture Notes on Clinical Skills has been used in the Oxford Clinical Medical School for over 35 years and is viewed as an essential guide in medicine. Although some doctors may use slightly different techniques in taking a history and physical examination, it is recommended that healthcare practitioners embarking on a career in healthcare use the techniques recommended in this Pocket Guide because they provide a sound approach for developing and employing clinical decision making.
Carol Lynn Cox
Acknowledgements
Special thanks are extended to Robert Turner and Roger Blackwood for granting permission for their text, Lecture Notes on Clinical Skills, to be used as a reference for this Pocket Guide. In addition, I am grateful to my students and healthcare practitioners that I have worked with over the years for encouraging me to create this Pocket Guide so that they could have an accessible tool for reference purposes in the clinical setting. This Guide has benefited from their suggestions as well as from medical colleagues with whom I currently practice. I am also grateful to Yogalakshmi Mohanakrishnan, Mitch Fitton, Copy Editor, Tom Marriott, Editorial Assistant, Vincent Rajan, Production Editor and the entire team at Wiley Publishers for their support in completing this Pocket Guide. Any faults or omissions in the text are entirely my own.
1Interviewing and History Taking
Carol Lynn Cox1,2
1 School of Health Sciences, City, University of London, London, UK
2 Health and Hope Clinics, Pensacola, FL, USA
1.1 General Procedures
1.1.1 Introduction
The patient's history is the major subjective source of data about their health status. It will give you insight into actual and potential problems as well as providing a guide for the physical examination. History taking involves obtaining the patient's chief complaint (quoted in the patient's words), a full review of systems from the patient's perspective, exploration of patient problems associated with the chief complaint, and other (frequently associated) problems that require addressing from the patient's perspective (Ball et al. 2014a, b; Barkauskas et al. 2002; Bickley and Szilagyi 2007, 2013; Cox 2010; Dains et al. 2012, 2015; Epstein et al. 2008; Japp and Robertson 2013; Jarvis 2008, 2015; Seidel et al. 2006, 2010; Swartz 2006; Talley and O'Connor 2006, 2014).
Figure 1.1 Usual sequence of events.
Source: Cox 2010. Reproduced with permission from John Wiley and Sons.
1.1.2 Approaching the Patient
Put the patient at ease by being confident and quietly friendly (Hatton and Blackwood
2003
; Jackson and Vessey
2010
; Rudolf and Levene
2011
; Sawyer
2012
).
Greet the patient: ‘Good morning, Mr/Mrs Smith’. (Address the patient formally and use the full name until the patient has given you permission for less formal address.)
Shake the patient's hand or place your hand on theirs if the patient is ill. (This action begins your physical assessment. It will give you a baseline indication of the patient's physical condition. For example, cold, clammy, diaphoretic, or pyrexial.)
State your name and title/role.
Make sure the patient is comfortable.
Explain that you wish to ask the patient questions to find out what the patient perceives is the problem or has happened.
Start the history taking by stating something like ‘I want to start by asking you some questions about your health’. (Always begin with general questions and then move to more specific questions (Cox 2010) Inform the patient how long you are likely to take and what to expect. For example, after discussing what has happened to the patient, explain that you would like to examine them.
1.1.3 Usual Sequence of Events (Figure 1.1)
1.1.3.1 Importance of the History
It identifies:
what the problem is or has happened
the personality of the patient
how the illness has affected the patient and family
any specific anxieties
the physical and social environment.
It establishes the practitioner–patient relationship.
It provides the foundation for your differential diagnoses.
It often gives the diagnosis.
Find the principal symptoms or symptom. Ask one of the following questions:
‘How may I help you?’
‘What has the problem been?’
‘Tell me, why have you come to the surgery/clinic/hospital today?’ or ‘Tell me why you came to see me today?’
Effective history taking involves allowing the patient to talk in an unstructured way whilst you maintain control of the interview. Use language that the patient can understand and avoid the use of medical jargon (Collins‐Bride and Saxe 2013; Cox 2010; Sawyer 2012; Tally and O'Connor 2014). Avoid asking questions that can be answered by a simple ‘yes’ or ‘no’. Ask questions that require a graded response. For example, ‘Describe how your headache feels’. Avoid using multiple‐choice questions that may confuse the patient (Cox 2010; Jackson and Vessey 2010). Ask one question at a time. Avoid asking questions like: ‘What's wrong?’ or ‘What brought you here?’ Use clarification to confirm your understanding of the patient's problem. Avoid forming premature conclusions about the patient's problem and above all remain nonjudgemental in your demeanour. Avoid making judgemental statements.
Let the patient tell their story in their own words as much as possible.
At first listen and then take discreet notes as the patient talks.
When learning to take a history there can be a tendency to ask too many questions in the first two minutes. After asking the first question you should normally allow the patient to talk uninterrupted for up to two minutes.
Do not worry if the story is not entirely clear or if you do not think the information being given is of diagnostic significance. If you interrupt too early, you run the risk of overlooking an important symptom or anxiety.
You will be learning about what the patient thinks is important. You have the opportunity to judge how you are going to proceed. Different patients give histories in very different ways. Some patients will need to be encouraged to enlarge on their answers to your questions; with other patients, you may need to ask specific questions and to interrupt in order to prevent too rambling a history. Think consciously about the approach you will adopt. If you need to interrupt the patient, do so clearly and decisively. Most important, do not give the impression you are in a hurry to conclude the discussion as this impression may cause the patient to withhold valuable information you need before commencing your physical examination.
Try, if feasible, to conduct a conversation rather than an interrogation, following the patient's train of thought.
You will usually need to ask follow‐up questions on the main symptoms to obtain a full understanding of what they were and of the chain of events.
Obtain a full description of the patient's principal complaints.
Enquire about the sequence of symptoms and events.
Beware pseudomedical terms, e.g. ‘gastric flu’ – enquire what happened. Clarify by asking what the patient means.
Do not ask leading questions.
A central aim in taking the history is to understand patients' symptoms from their own point of view. It is important not to tarnish the patient's history by your own expectations. For example, do not ask a patient whom you suspect might be thyrotoxic: ‘Do you find hot weather uncomfortable?’ This invites the answer ‘yes’ and then a positive answer becomes of little diagnostic value. Ask the open question: ‘Do you particularly dislike either hot or cold weather?’ (Ball et al. 2014a, b; Bickley and Szilagyi 2013; Coulehan 2006).
Be sensitive to a patient's mood and nonverbal responses.
For example, hesitancy in revealing emotional content. Use reflection so that the patient will expand on their discussion.
Be understanding, receptive, and matter of fact without being sympathetic. Display and express empathy rather than sympathy.
Avoid showing surprise or reproach.
Clarify symptoms and obtain a problem list.
When the patient has finished describing the symptom or symptoms:
briefly summarise the symptoms
ask whether there are any other main problems (Coulehan
2006
).
For example, say, ‘You have mentioned two problems: pain on the left side of your tummy, and loose motions over the last six weeks. Before we talk about those in more detail, are there any other problems I should know about?’
1.1.4 Usual Sequence of History
nature of principal complaints, e.g. chest pain, poor home circumstances
history of present complaint
details of current illness
enquiry of other symptoms (see Functional Enquiry)
past history
family history
personal and social history
If one's initial enquiries make it apparent that one section is of more importance than usual (e.g. previous relevant illnesses or operation), then relevant enquiries can be brought forward to an earlier stage in the history (e.g. past history after finding principal complaints).
1.1.5 History of Present Illness
Start your written history with a single sentence summing up what your patient's complaint is. It should be like the banner headline of a newspaper. For example: c/o chest pain for six months.
(It is best to state in quotation marks the patient's chief complaint in the patient's own words when documenting.)
Determine the chronology of the illness by asking:
‘How and when did your illness begin?’ or
‘When did you first notice anything wrong?’ or
‘When did you last feel completely well?’
Begin by stating when the patient was last perfectly well. Describe symptoms in chronological order of onset.
Both the date of onset and the length of time prior to being seen by you should be recorded. Symptoms should never be dated by the day of the week as this later becomes meaningless (Bickley and Szilagyi 2007, 2013; Cox 2010).
Obtain a detailed description of each symptom by asking:
‘Tell me what the pain was like’, for example. Make sure you ask about all symptoms, whether they seem relevant or not.
With all symptoms obtain the following details:
duration
onset – sudden or gradual
what has happened since:
constant or periodic
frequency
getting worse or better
precipitating or relieving factors
associated symptoms.
If pain is a symptom also determine the following:
site
radiation
character, e.g. ache, pressure, shooting, stabbing, dull
severity, e.g. ‘Did it interfere with what you were doing?’ ‘Does it keep you awake?’ ‘Have you ever had this type of pain before?’ ‘Does the pain make you sweat or feel sick to your stomach?’
Avoid technical language when describing a patient's history. Do not say ‘the patient complained of melaena’, rather: ‘the patient complained of passing loose, black, tarry motions’.
1.1.6 Supplementary History
When patients are unable to give an adequate or reliable history, the necessary information must be obtained from friends or relations. A history from a person who has witnessed a sudden event is often helpful.
When the patient does not speak English, arrange for an interpreter to translate for the patient. Bear in mind that numerous authors (Barkauskas et al. 2002; Ball et al. 2014a; Bickley and Szilagyi 2013; Cox 2010; Jarvis 2015; Rhoads and Paterson 2013) indicate that, if possible, family members and patients' young children should not be used as interpreters. Family members will frequently tell you what they think the patient's problem is rather than what the patient thinks the problem is. Because some questions that you may ask the patient are sensitive in nature, children should not be asked to interpret for their parents (Cox 2010; Lack 2012).
1.2 Functional Enquiry
This is a checklist of symptoms not already discovered.
Do not ask questions already covered in establishing the principal symptoms. This list may detect other symptoms.
Modify your questioning according to the nature of the suspected disease, available time, and circumstances (Lack
2012
).
If during the functional enquiry a positive answer is obtained, full details must be elicited. Asterisks (*) denote questions that must nearly always be asked.
1.2.1 General Questions (These May Be Considered as Part of your Review of Systems)
Ask about the following points:
*appetite: ‘What is your appetite like? Do you feel like eating?’
*weight: ‘Have you lost or gained weight recently?’
*general well‐being: ‘Do you feel well in yourself?’
*feelings of sadness or depression (to rule out feelings of suicide): ‘Do you feel sad or depressed?’
fatigue: ‘Are you more or less tired than you used to be?’
fever or chills: ‘Have you felt hot or cold? Have you shivered?’
night sweats: ‘Have you noticed any sweating at night or any other time?’
aches or pains
rash: ‘Have you had any rash recently? Does it itch?’
lumps and bumps.
1.2.2 Cardiovascular and Respiratory System
Ask about the following points:
*chest pain: ‘Have you recently had any pain or discomfort in the chest?’
The most common causes of chest pain are:
ischaemic heart disease
: severe constricting, central chest pain radiating to the neck, jaw, and left arm;
angina
: pain frequently precipitated by exercise or emotion and relieved by rest;
myocardial infarction
; the pain may come on at rest, be more severe, and last hours
pleuritic pain
: sharp, localised pain, usually lateral; worse on inspiration or cough
anxiety or panic attacks
: a very common cause of chest pain. Enquire about circumstances that bring on an attack.
*shortness of breath: ‘Are you breathless at any time?’
Breathlessness (dyspnoea) and chest pain must be accurately described. The degree of exercise that brings on the symptoms must be noted (e.g. climbing one flight of stairs, after 0.5 km [1/4 mi] walk).
shortness of breath on lying flat (
orthopnoea
): ‘Do you get breathless in bed? What do you do then? Does it get worse or better on sitting up? How many pillows do you use? Can you sleep without them?’
waking up breathless: ‘Do you wake at night with any symptoms? Do you gasp for breath? What do you do then?’
Orthopnoea (breathless when lying flat) and paroxysmal nocturnal dyspnoea (waking up breathless, relieved on sitting up) are features of left heart failure.
*
ankle swelling
Common in congestive cardiac failure (right heart failure).
palpitations: ‘Are you aware of your heart beating?’
Palpitations may be:
single thumps (
ectopics
)
slow or fast
regular or irregular
Ask the patient to tap them out.
Paroxysmal tachycardia (sudden attacks of palpitations) usually starts and finishes abruptly.
*cough: ‘Do you have a cough? Is it a dry cough or do you cough up sputum? When do you cough?’
sputum: ‘What colour is your sputum? How much do you cough up?’
Green sputum usually indicates an acute chest infection. Clear sputum daily during winter months suggests chronic bronchitis. Frothy sputum suggests left heart failure.
*blood in sputum (
haemoptysis
): ‘Have you coughed up blood?’
Haemoptysis must be taken very seriously. Causes include:
carcinoma of bronchus
pulmonary embolism
mitral stenosis
tuberculosis
bronchiectasis
blackouts (
syncope
): ‘Have you had any blackouts or faints? Did you feel light‐headed or did the room go round? Did you lose consciousness? Did you have any warning? Can you remember what happened?’
*smoking: ‘Do you smoke? How many cigarettes do you smoke each day?’
1.2.3 Gastrointestinal System
Ask about the following points:
nausea: ‘Are there times when you feel sick?’
vomiting: ‘Do you vomit? What is it like?’
‘Coffee grounds’ vomit suggests ‘altered’ blood such as with a bleeding ulcer.
Old food suggests pyloric stenosis.
If blood, what colour is it – dark or bright red?
difficulty in swallowing (
dysphagia
): ‘Do you have difficulty swallowing? Where does it stick?’
For solids: often organic obstruction.
For fluids: often neurological or psychological.
indigestion: ‘Do you have any discomfort in your stomach after eating?’
abdominal pain: ‘Where is the pain? How is it connected to meals or opening your bowels? What relieves the pain?’
*bowel habit: ‘How often do you open your bowels?’ or ‘How many times do you open your bowels per day?’ ‘Do you have to open your bowels at night?’ (often a sign of true pathology)
If diarrhoea is suggested, the number of motions per day and their nature (blood? pus? mucus?) must be established. Frothy, frequent diarrhoea may be suggestive of coeliac disease.
‘What are your motions like?’ The stools may be pale, bulky, and float (fat in stool – steatorrhoea) or tarry from digested blood (melaena – usually from upper gastrointestinal tract).
Bright blood on the surface of a motion may be from haemorrhoids, whereas blood in a stool may signify cancer or inflammatory bowel disease.
Question what the patient has eaten. Red stool may indicate the patient has been eating beets, for example.
jaundice: ‘Is your urine dark? Are your stools pale? What tablets have you been taking recently? Have you had any recent injections or transfusions? Have you been abroad recently? How much alcohol do you drink?’
Jaundice may be:
obstructive (dark urine, pale stools) from:
carcinoma of the head of the pancreas
gallstones
hepatocellular (dark urine, pale stools may develop) from:
ethanol
(cirrhosis)
drugs or transfusions (viral hepatitis)
drug reactions or infections (travel abroad, viral hepatitis, or amoebae)
haemolytic (unconjugated bilirubin is bound to albumin and is not secreted in the urine).
1.2.4 Genitourinary System
Ask about the following points:
dysuria: pain on urination – usually burning (often a sign of infection/cystitis)
loin pain: ‘Any pain in your back?’
Pain in the loins suggests pyelonephritis.
*urine: ‘Are your waterworks all right? Do you pass a lot of water at night? Do you have any difficulty passing water? Is there blood in your water?’ (suggests haematuria)
Polyuria and nocturia occur in diabetes.
Prostatism results in slow onset of urination, a poor stream, and terminal dribbling.
sex: ‘Any problems with intercourse or making love?’
*menstruation: ‘Any problems with your periods? Do you bleed heavily? Do you bleed between periods?’
Vaginal bleeding between periods or after the menopause raises the possibility of cervical or uterine cancer.
Menstrual cycle: Last menstrual period (LMP) and length of bleeding. (Normal cycle is 21–35 days. Normal period is between 5 and 8 days with between 70 and 200 ml of blood loss.) If indicated, ask about intermenstrual bleeding, postmenopausal bleeding or postcoital bleeding.
vaginal discharge (if present, ask about colour, consistency, and odour; does it cause itching?)
pain on intercourse (
dyspareunia
).
1.2.5 Nervous System
Ask about the following points:
*headache: ‘Do you ever have any headaches? Where are they?’ (location) ‘When do you get headaches?’ ‘What are they like?’ (quality/intensity)
Headaches often originate from tension and can be either frontal or occipital. Occipital headache on waking in the early morning may be due to raised intracranial pressure (e.g. from a tumour or malignant hypertension). Ask if the headache is associated with flashing lights (amaurosis fugax) (Bickley and Szilagyi 2013; Cox 2010).
vision: ‘Do you have any blurred or double vision?’
hearing: ask about tinnitus, deafness, and exposure to noise
dizziness: ‘Do you have any dizziness or episodes when the world goes round (
vertigo
)?’
Dizziness with light‐headed symptoms, when sudden in onset, may be cardiac (enquire about palpitations). When slow, onset may be vasovagal ‘fainting’ or an internal haemorrhage.
Vertigo may be from ear disease (labyrinthitis/infection, Ménière's disease, Benign Paroxysmal Positional Vertigo [BPPV] ‘Ear Crystals’ and/or age related)
Enquire about deafness, earache, or discharge or brain‐stem dysfunction.
unsteady gait: ‘Any difficulty walking or running?’
weakness (consider myelinating encephalophy [
ME
] or
myasthenia gravis
)
numbness or increased sensation: ‘Any patches of numbness?’
pins and needles
sphincter disturbance: ‘Any difficulties holding your water/bowels?’ (sign of spinal cord compression; ask about back injury)
Fits or faints: ‘Have you had any funny episodes?’ (
Syncope – consider cardiac related
, e.g.
postural orthostatic tachycardia syndrome [POTS] – disautonomia
)
The following details should be sought from the patient:
duration
frequency and length of attacks
time of attacks, e.g. if standing, at night
mode of onset and termination
premonition or aura, light‐headedness, or vertigo
biting of tongue, loss of sphincter control, injury, etc.
Grand mal epilepsy classically produces sudden unconsciousness without any warning and on waking the patient feels drowsy with a headache, has a sore tongue, and has been incontinent.
1.2.6 Mental Health
Ask about the following points:
depression: ‘How is your mood? Happy or sad? If depressed, how bad? Have you lost interest in things? Can you still enjoy things? How do you feel about the future?’ ‘Has anything happened in your life to make you sad or depressed? Do you feel guilty about anything?’ If the patient seems depressed: ‘Have you ever thought of suicide? How long have you felt like this? Is there a specific problem? Have you felt like this before?’
active periods: ‘Do you have periods in which you are particularly active?’
Susceptibility to depression may be a personality trait. In bipolar affective disorder, swings to mania (excess activity, rapid speech, and excitable mood) can recur. Enquire about interest, concentration, irritability, sleep difficulties.
In schizophrenia active periods are associated with paranoia (in conjunction with bipolar affective disorder the term is schizoaffective disorder)
anxiety: ‘Have you worried a lot recently? Do you get anxious? In what situations? Are there any situations you avoid because you feel anxious?’ ‘Do you worry about your health? Any worries in your job or with your family? Any financial worries?’ ‘Do you have panic attacks? What happens?’
sleep: ‘Any difficulties sleeping? Do you have difficulty getting to sleep? Do you wake early?’
Difficulties of sleep are commonly associated with depression or anxiety.
In schizoaffective disorder both bipolar and schizophrenic behaviours are exhibited.
1.2.7 The Eye
Ask about the following points:
eye pain, photophobia, or redness: ‘Have the eyes been red, uncomfortable, or painful?’
painful red eye, particularly with photophobia, may be serious and due to:
iritis (uveitis) – anterior/posterior uveitis must be treated as a medical emergency (it may be related to ankylosing spondylitis, Reiter's disease, sarcoid, Behçet's disease. Uveitis is also seen in conjunction with ulcerative colitis and Crohn's disease.)
scleritis (systemic vasculitis)
corneal ulcer
acute glaucoma
painless red eye may be:
episcleritis
temporary and of no consequence
systemic vasculitis
sticky red eye may be
conjunctivitis
(usually infective)
itchy watery eye may be
allergic
, e.g.
hay fever
gritty eye may be dry (sicca or
Sjögren's syndrome
)
clarity of vision: ‘Has your vision been blurred?’
blurring of vision for either near or distance alone may be an error of focus, helped by spectacles
blurred vision in general (
serous retinopathy
)
loss of central vision (or of top or bottom half) in one eye may be due to a
retinal or optic nerve disorder
transient complete blindness in one eye lasting for minutes –
amaurosis fugax
(fleeting blindness)
suggests retinal arterial blockage from embolus
may be from
carotid atheroma
(listen for bruit)
may have a cardiac source
subtle difficulties with vision, difficulty reading – problems at the chiasm, or visual path behind it:
complete
bitemporal hemianopia – tumour
pressure on chiasm
homonymous
hemianopia
:
posterior cerebral
or
optic radiation lesion
usually
infarct
or
tumour
; rarely complains of ‘half vision’, but may have difficulty reading
Diplopia: ‘Have you ever seen double?’
Diplopia may be due to:
lesion
of the motor cranial nerves III, IV, or VI
3rd‐nerve palsy
causes double vision in all directions often with dilatation of the pupil and ptosis
4th‐nerve palsy
causes doubling looking down and in (as when reading) with images separated horizontally and vertically and tilted (not parallel)
6th‐nerve palsy
causes horizontal, level, and parallel doubling
worse on looking to the affected side
muscular disorder
e.g. thyroid related (see below)
ME
(weakness after muscle use, antibodies to nerve end plates)
Refer to Chapter 10 for more comprehensive information on examination of the eye.
1.2.8 Musculoskeletal System
Ask about the following points:
pain, stiffness, or swelling of joints: ‘When and how did it start? Have you injured the joint?’
There are innumerable causes of arthritis (painful, swollen, tender joints) and arthralgia (painful joints). Patients may incorrectly attribute a problem to some injury.
Osteoarthritis is a joint ‘wearing out’ and is often asymmetric, involving weight‐bearing joints such as the hip or knee. Exercise makes the joint pain worse.
Rheumatoid arthritis is a generalised autoimmune disease with symmetrical involvement. In the hands, fusiform swelling of the interphalangeal joints is accompanied by swollen metacarpophalangeal joints. Large joints are often affected. Stiffness is worse after rest, e.g. on waking, and improves with use.
Gout usually involves a single joint, such as the first metatarsophalangeal joint, but can lead to gross hand involvement (also seen in the elbows and ankles) with asymmetric uric acid lumps (tophi) by some joints and in the tips of the ears.
Septic arthritis is a single, hot, painful joint.
functional disability: ‘How far can you walk? Can you walk up stairs? Is any particular movement difficult? Can you dress yourself? (Observe how the patient is dressed.) How long does it take?’ ‘Are you able to work?’ ‘Can you write?’ (In the physical examination observe how the patient walks and their manual dexterity.)
Refer to Chapter 11 for more comprehensive information on examination of the musculoskeletal system.
1.2.9 Thyroid Disease
Ask about the following points:
weight change
reaction to the weather: ‘Do you dislike the hot or cold weather?’
irritability: ‘Are you more or less irritable compared with a few years ago?’
diarrhoea/constipation
palpitations
dry skin or greasy hair: ‘Is your skin dry or greasy? Is your hair dry or greasy?’
depression: ‘How has your mood been?’
croaky voice
Hypothyroid patients put on weight without increase in appetite; dislike cold weather; have dry skin and thin, dry hair, a puffy face, a croaky voice; are usually calm; and may be depressed.
Hyperthyroid patients may lose weight despite eating more, dislike hot weather, perspire excessively, have palpitations and a tremor, and may be agitated and tearful. Young people have predominantly nervous and heat intolerance symptoms, whereas old people tend to present with cardiac symptoms. (Exophthalmos may be present.)
1.3 Past History
All previous illnesses or operations, whether apparently important or not, must be included.
For instance, a casually mentioned attack of influenza or chill may have been a manifestation of an occult infection.
The importance of a past illness may be gained by finding out how long the patient was in bed or off work (Lack
2012
).
Complications of any previous illnesses should be carefully enquired into and, here, leading questions are sometimes necessary.
1.3.1 General Questions
Ask about the following:
‘Have you had any serious illnesses?’
‘Have you had any emotional or nervous problems?’
‘Have you had any operations or admissions to hospital?’
‘Have you ever:
had yellow skin (jaundice), fits (epilepsy), tuberculosis, high blood pressure (hypertension), low blood pressure (hypotension), rheumatic fever, kidney problems, or diabetes?
travelled abroad?
had allergies?’
‘Have any medicines ever upset you?’
Allergic responses to drugs may include an itchy rash, vomiting, diarrhoea, or severe illness, including jaundice. Many patients claim to be allergic but are not. An accurate description of the supposed allergic episodes is important.
Other questions can be included when relevant such as:
‘Have you ever had a heart attack?’
Additional questions can be asked depending on the patient's previous responses such as:
if the patient has high blood pressure, ask about kidney problems, if relatives have hypertension, or whether the patient eats liquorice
if a possible heart attack, ask about hypertension, diabetes, diet, smoking, family history of heart disease
if the history suggests cardiac failure, you must ask if the patient has had
rheumatic fever
Patients have often had examinations for life insurance, disability insurance, or the armed forces.
1.4 Family History
The family history gives clues to possible predisposition to illness (e.g. heart attacks) and whether a patient may have reason to be particularly anxious about a certain disease (e.g. mother died of cancer).
Death certificates and patient knowledge are often inaccurate. Patients may be reluctant to talk about relatives' illnesses if they were mental disorders, epilepsy, or cancer (Cox 2010).
It will be useful to construct a genogram of the patient's family history for quick referral.
