It is helpful to both the patient and the doctor to signal the end of the taking of the history as a preliminary to the physical (or mental I examination, There are two elements to closure - an opportunity to acquire further information which has been forgotten or undisclosed, then a review of the history.
The opportunity to provide further information should be given to the patient. As the history is being taken, anxiety and embarrassment may diminish, and rapport and trust develop. This may enable the patient to divulge information to the doctor that the patient had not disclosed earlier. T his is not always relevant, but from the patient's perspective it
• when further information raises possibilities of disease or disorder affecting other systems, e.g. family history of a particular disease, past medical history, patient's medication, admission of alcohol abuse
• when observation of the patient raises possibilities of disease or disorder in other systems, e.g. smelling of alcohol, being breathless, having exophthalmos
• a more general, speculative 'trawl' in a patient who may be at greater risk of unrecognised disease, e.g. the homeless. the elderly, or patients who are not registered with a general practice.
It is better to incorporate any positive or important negative information gained during the systemic enquiry into the main history, rather than considering this part as a separate entity.
may need to be shared. The fact that this has happened should signal to the doctor that an effective interview has taken place.
History-taking also acts as a prompt, directing the patient's attention, and this may result in retrieval of memory.
The summary should be presented by the clinician and pick out what the clinician considers to be the main points.
» A clinical history has a basic structure consisting of a series of elements or 'nests' which vary in relevance and Importance from case to case.
• The history of the presenting complaint is the first and most important nest. II should be considered in layers, beginning with the patient's free account, then refining the clinical features, then reviewing the subjective effects of the illness and finally evaluating the patient's standpoint (attitudes, understanding and wishes).
• The essence of history-taking is to place emphasis on those diagnostic possibilities which require to be urgently excluded or for which there is specific treatment. The specific questions which should be asked will depend upon the nature of the problem.
• Drug allergies/reactions require specific inquiry.
• The social history should be slanted appropriately for the patient's age. background and presentation. Inappropriate inquiries may antagonise patients. Sensitive areas ol inquiry need to be recognised and managed as such.
• The use of tobacco and alcohol should be determined with an estimate of consumption.
• Closed questions and cross-checking of Inquiries may be necessary when assessing the use of tobacco, alcohol and illicit drugs, and compliance with treatment.
• The completion of history-taking should be signalled with a summary ol the presentation which the patient can correct or amplify.
Anything incorporated from the background history should have an obvious relevance. This summary should be put to the patient for confirmation, correction, expansion or alteration of emphasis. The aim is to agree a distillation of the problem for which the patient seeks help.
PATIENTS WHO PRESENT DIFFICULTY IN
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