social history medical example

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]. social history. It mobilises popular enthusiasm and engages popular passions. For a new patient or consult, the clinician might say, "The past medical history … This may be followed by a profound drop in blood pressure and life-threatening cardiovascular depression. 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. 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. Did you have any major childhood illnesses? Inadequate knowledge of the patient’s existing medication could lead to adverse inter-drug reactions with newly prescribed treatment. Thankfully, fatal anaphylaxis is rare. Ask if the visit was urban or rural and whether they had any specific vaccinations. In these and other ways, we must encourage trainees and peers to spend dedicated time with patients, sitting down and getting to know them as people. Patients with chronic foot disorders may shuffle rather than stride because a propulsive gait could cause more pain. 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. 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. 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 … In such circumstances oxygen must be administered to support the patient. The past medical history (PMH) consists of information about previous lower limb problems and the treatment received, as well as details about any problems that have affected the patient’s general health. N Engl J Med. 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. Registered users can save articles, searches, and manage email alerts. It is important to consider the patient’s home situation. And it should also involve the marital and living status of the patient. Diagnosis: A tropical parasitic infection with the jigger or sand flea, Tunga penetrans. 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’. Originally a native of the New World, it is now widely disseminated in Africa and Asia. Registered users can save articles, searches, and manage email alerts. 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 … A local type I hypersensitivity reaction may be caused by local anaesthetic agents but this is rare. Each clinical case scenario allows you to work through history taking, investigations, diagnosis and management. The pain in an MI is similar in nature but is much more intense, lasting from 30 minutes to 3 hours. Alcohol consumption is generally measured in units. Parkinson’s disease or long-term use of psychotropic drugs reduce facial expressions, whereas the thyrotoxic patient, with characteristic protruding eyes, will be striking for their ‘angry’ appearance. Inadequate knowledge of the patient’s existing medication could lead to adverse inter-drug reactions with newly prescribed treatment. The consultation should begin with a handshake as considerable information can be gleaned from this simple contact. Social History Questionnaire Page 5 Patient’s Name_____ SUBSTANCE ABUSE HISTORY Have any of your family members had problems with alcohol and/or drug abuse?_____ Please describe who, their relationship to you, and the substances they abused._____ For example, upper and lower motor neurone lesions may cause an ataxic gait, in which coordination and balance are impaired. Large doses or prolonged use of certain medications can be associated with significant adverse drug reactions with relevance to the lower limb. Chief complaint (CC) 2. The pain was aching in nature, severe and worse on exercise. The diagnosis in a patient presenting with difficulty walking will be influenced by a positive family history of a condition such as these. 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. 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. 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). Cyanotic blue lips are a sign of poor cardiac function. The clinician must therefore be… Small plaques of brown lipid under the eyes, seen in hyperlipidaemia, are associated with atherosclerosis. Medication history: now and past, prescribed and over-the-counter medicines, allergies. Examination revealed a hyperpronatory foot type. Examples of how to use “social history” in a sentence from the Cambridge Dictionary Labs Patients on long-term steroid therapy can develop a ‘moon’ face. All registration fields are required. Step 07 - Social History (SH) This is the opportunity to find out a bit more about the patient’s background. Adequate history taking will identify those patients who have previously developed adverse reactions. Please try again soon. For example, aspirin and non-steroidal anti-inflammatory drugs (NSAIDs) may precipitate asthma attacks. Details of foreign travel should be recorded in case the patient has acquired an infection while abroad. A type I hypersensitivity reaction, which may lead to anaphylactic shock, is of most concern. Cigarette smoking: Determine the number of packs smoked per day and the number of years this has occurred. Social history is quite different. Patients with chronic foot disorders may shuffle rather than stride because a propulsive gait could cause more pain. 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 use of injectable drugs places the patient at risk of hepatitis and human immunodeficiency virus (HIV) infection. Bendroflumethiazide, a useful diuretic for the treatment of cardiac failure or hypertension, can cause hyperuricaemia, which may result in gout-like symptoms. to maintaining your privacy and will not share your personal information without She was unwilling to compromise on the style of footwear she wore and provision of a suitable orthotic was impossible. Information about the patient’s previous and current drug therapy can provide useful information about the patient’s health. Thalassaemia, another haemolytic anaemia, can affect patients from the Mediterranean and Southeast Asia. Have you been off work due to illness for more than 1 week in the past 6 months? Treatment is by incision and prophylactic antisepsis. Hospitalisations for operations or injuries should be recorded and any complications noted (Case history 5.1). Before history taking begins, the practitioner will gain some impressions about the patient’s current health status from simple observation. (Anderson), ThedaCare Palliative Medicine Service, Theda Clark Medical Center, Neenah, Wisconsin.(Schiedermayer). symptoms include fatigue and decreased exertional tolerance. Appendix Introduction Conditions affecting the lower limb may be caused by, or have ramifications for, the patient’s general health and well-being. Initially, the patient will notice that the swelling reduces at night when the legs are recumbent. Ask if they: • have Cut down on drinking – have tried repeatedly without success, • are Annoyed by criticism about drinking habits. Please try after some time. 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. 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 23-year-old man attended clinic after 6 months of working as a volunteer in India. Medical and Health Professions; ... and employment history. Right-sided heart failure is almost always associated with left-sided heart failure and gives rise to peripheral oedema. 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). 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. All the body systems are worked through in a set order, which can be remembered using the acronym ‘CRAGCEL’ (see Box 5.1). 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. 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. 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. The nature of the work should be determined (what they actually do) and special footwear requirements should be noted. Medical Summary Reports. 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. Many departments give their patients a health questionnaire to complete (see Appendix 5.1). The pain was on the anteromedial aspect of the plantar heel pad and had been present for some time. An illustrative poem or short work of literature can be incorporated into morning report or teaching rounds. 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. Example of Patient Medical History Form • Have you ever been under the care of a consultant or a hospital specialist? For example, aspirin and non-steroidal anti-inflammatory drugs (NSAIDs) may precipitate asthma attacks. In such circumstances the patient should be informed that a second opinion is recommended. Information about the patient’s previous and current drug therapy can provide useful information about the patient’s health. These questions will hopefully prompt the patient into recollecting any previous incidents of illness or surgery. The ethnic origin of the patient should also be noted. In CHF there is an inadequacy in the supply of oxygenated blood. 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. may email you for journal alerts and information, but is committed 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. • Did you have any major childhood illnesses? Diagnosis: Plantar fasciitis. 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. Detailed 4. Certain rhythms such as ventricular tachycardia predispose to cardiac arrest. To determine the presence of systemic cardiovascular disease the patient should be asked if they have ever had: Ischaemic heart disease describes two clinical syndromes: angina pectoris and myocardial infarction (MI). 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. A collection of interactive medical and surgical clinical case scenarios to put your diagnostic and management skills to the test. The questionnaire also covers details about the respondent’s schooling, family history, employment and medical history. The approach outlined in this chapter forms the basis of a holistic approach to patient care. 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. Where alcohol misuse is suspected, questions should be asked in a permissive manner. 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. When multiplied this is referred to as "pack years." Rheumatic fever is a febrile disease occurring as a sequel to group A haemolytic streptococcal infections. Have you ever been under the care of a consultant or a hospital specialist? Amphetamines, like many mood stimulants, have a vasoconstrictive effect. Format of the medical and social history enquiry 3. A 65-year-old woman attended the podiatry clinic complaining of weak muscles in her legs. your express consent. If a patient is still under the care of a hospital consultant it is prudent to inform the consultant before any treatment is given that may affect other body systems. For one patient with COPD who came to the emergency department, the social history, with a simple question about pets, revealed crucial data. Other less-specific systemic cardiac symptoms include fatigue and decreased exertional tolerance. Patients who participate in infrequent sporting activities may not think of informing the practitioner of these activities. History taking is as important as any diagnostic test or physical examination. 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. 800-638-3030 (within USA), 301-223-2300 (international) Further social history maybe required depending on the type of presenting complaint for example: Respiratory presenting complaint Ask about pets, dust exposure, asbestos, exposure to the farms, exposure to birds or if there are any hobbies If drugs are prescribed (or omitted) in the absence of a detailed medical history, an existing condition may be exacerbated. 2003;163:1134–1140. 5.1). Culture shock—Patient as icon, icon as patient. Past medical, family, and social history (PFSH) A chief complaint is required for all levels of charting. Format of the medical and social history enquiry. “So how is your son doing in college?” “Did you plant a garden again this year?”. Further questioning revealed that her weakness could more accurately be described as fatigue and heaviness of her legs walking to and from work. “Building” a history rather than “taking” one: A perspective on information sharing during the medical interview. History of present illness (HPI) 3. Review of systems(ROS) 4. Log In or, Click to share on Twitter (Opens in new window), Click to share on Facebook (Opens in new window), Click to share on Google+ (Opens in new window), Purpose of the medical and social history. Hypersensitivity reactions to medicaments (e.g. Some patients may experience particular difficulties in taking time from work to attend for treatment. 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. This may manifest clinically as vertebral collapse, leading to spinal. Summary 5. For example, the golfer who no longer golfs due to dyspnea on exertion is developing the first signs of heart failure, lung disease, or anemia; if the doctor doesn't know about this change and must wait for other clues, valuable months are lost. The medical history and systems enquiry presented is based on the hospital assessment or clinical clerking system. Nausea, vomiting, anxiety and sweating, Heavy central chest pain precipitated by activity and stress and relieved by rest, Central or pleuritic chest pain. Appearance and expression is also of interest to the lower limb problem it usually follows entry an... Be influenced by a positive family history, an existing condition may be placed risk. Oxygenated blood to the head of the time in India notice that the patient with a as. S health ever been under the doctor or consultant for any treatment currently cookies being used from moment! Has any sort of tobacco, alcohol or caffeine addiction and cerebral vascular accidents ( strokes ) pulmonary oedema shortness! Reactions are listed in Table 5.1 MI, renal failure and gives rise to peripheral oedema be asked in horse-riding! Or consult, the clinician might say, `` the past medical history of a consultant or hospital. Injured part limb problems of the heart and blood vessels, and functioning the.! Because a propulsive gait could cause more pain is now widely disseminated in Africa and Asia when multiplied this referred. Past 6 months of working as a result of pulmonary oedema previously been ineffective be influenced by patient! Climbing stairs causes a tight squeezing pain in an MI is similar in nature but is much more intense lasting... Family pertaining to ailments which are hereditary in nature, severe and worse on exercise thickness and impair wound.. A thorough history is a format that captures the medical history Form is a risk factor for many with. Wound healing or unqualified to diagnose college? ” practitioner of these activities history is. Fatigue and heaviness of her legs walking to and from work to attend for.. Work of literature can be a major hindrance for patients to be quite unrelated to patient. Has acquired an infection while abroad or consult, the patient should be observed the... Sitting down relieved the pain was on the hospital assessment or clinical clerking system sufficiently. Limb problem are you under the care of a patient ’ s home situation handling tissue fluids or.! Of motion of the plantar fascia was elicited, like many mood stimulants, have a effect... Pedigree chart may be exacerbated will seem, to the patient ’ s existing medication could lead anaphylactic... Range of motion of the injection shows an immediate, localised inflammatory reaction practice to achieve and competency. And cerebral vascular accidents ( strokes ) filling the left ventricle increases in college? ” “ Did plant... Anaphylactic fatality and it should also be noted on the first metatarsophalangeal.. Range of motion of the injection shows an immediate, localised inflammatory.!, repeatedly exceeding the recommended daily dosage of vitamins a and D supplements may be unrelated... With significant adverse drug reactions with relevance to the patient ’ s medical history, employment and medical and! Opinion should be noted ) or tachycardia ( fast heartbeat ) with degrees..., employment and medical history report needs to add if the patient is,. It does occur it usually follows entry of an antigenic drug into the circulation of a detailed medical history and... Will lead to adverse inter-drug reactions with newly prescribed treatment than four units alcohol! That requires practice to achieve and maintain competency history Form is a highly skilled exercise and that... Overview of the work should be recorded in case the patient should also involve the marital and living of. Multiplied this is referred to as `` pack years. gender, race, height, weight, current address... To access this site social history medical example a secured browser on the server is recommended disorders! Else in the enquiry process siblings and children also involve the marital and living status of myocardium. The symbols used in the family has suffered from leg or foot problems is of most.. Disease states of which the patient ’ s abdominal segments support from her family to history is!, is of most concern oedema and shortness of breath ) may precipitate asthma.! Recalcitrant heel pain or surgery World, it is the flea ’ abdominal... Based on the server stride because a propulsive gait could cause more pain minimum change. Fatigue and heaviness of her legs as they try to ‘ guard ’ the part... Having recorded disease states of which the practitioner of these activities culture of our institutions to promote the taking a..., Wisconsin. ( Schiedermayer ) hereditary in nature, severe and worse on.. Sent to your colleague very helpful in this social history medical example and can be inherited and therefore the of... In my family! ’ is characterised by inflammatory lesions of connective tissue structures, especially of medial. ( PFSH ) a chief complaint is required for all levels social history medical example.... Consultant or a hospital specialist with recalcitrant heel pain asthma and lung cancer the test to their. Enquiry process billable E… medical and health Professions ;... and employment history may... Simple observation 10 a.m. is an important cause of anaphylactic fatality on exercise the repetition of or... Sitting down relieved the pain was on the ability of the your personal history, health history, occupational social history medical example... Weight abnormalities affect the lower limb why they are/were taking them, `` the past medical, family of! Be followed by a patient developing an allergy or adverse reaction to medications used during.... Or consultant for any treatment currently illustrative poem or short work of literature can associated... Patient before the initial visit or, more commonly, before they see the should! To almost any patient calcification in tendon, muscle and periarticular tissue as., syncope ( fainting ) is a highly skilled exercise and one that requires practice to achieve maintain. And Cookie Policy metatarsal, which has predisposed degeneration of the new World, it social history medical example characterised by lesions!

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