For immediate assistance, contact Customer Service: 800-638-3030 (within USA), 301-223-2300 (international). A 23-year-old secretary presented with pain in the first metatarsophalangeal joint. She was unwilling to compromise on the style of footwear she wore and provision of a suitable orthotic was impossible. “My dog becomes visibly agitated and starts barking after smelling my breath when I'm getting sick,” she offered quickly … For one patient with COPD who came to the emergency department, the social history, with a simple question about pets, revealed crucial data. Are you exposed to passive smoking at home? Social History Assessment is the first resource to offer practical guidance about interpreting the social history. Social history is quite different. Your account has been temporarily locked due to incorrect sign in attempts and will be automatically unlocked in This condition can have a direct effect on the ability of the muscles to function under strain. The risk of such a clinical emergency can be minimised by adhering to the maximum safe dose for the various local anaesthetic agents and always having oxygen available. 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. 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. The ethnic origin of the patient should also be noted. ThedaCare Palliative Medicine Service, Theda Clark Medical Center, Neenah, Wisconsin. 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. The pain was on the anteromedial aspect of the plantar heel pad and had been present for some time. The differential diagnosis includes MI, angina pectoris, pneumonia, pericarditis and oesophageal reflux. 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. Some patients may experience particular difficulties in taking time from work to attend for treatment. Active sportsmen and women may make the association between their sport and a lower limb problem, but those who participate in occasional sporting activities and hobbies may not. The central black dot is the flea’s abdominal segments. To compensate for this, first the heart rate and then the volume of blood filling the left ventricle increases. 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. Lack of home support may rule out certain forms of treatment. • Have you ever been under the care of a consultant or a hospital specialist? 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. An X-ray revealed a compression fracture to the head of the first metatarsal, which has predisposed degeneration of the joint. Registered users can save articles, searches, and manage email alerts. The varied needs of older patients may require different interviewing techniques. For one patient with COPD who came to the emergency department, the social history, with a simple question about pets, revealed crucial data. to maintaining your privacy and will not share your personal information without Patients with acute foot or leg pain will walk with a limp as they try to ‘guard’ the injured part. Patients with chronic foot disorders may shuffle rather than stride because a propulsive gait could cause more pain. A local type I hypersensitivity reaction may be caused by local anaesthetic agents but this is rare. Have you been off work due to illness for more than 1 week in the past 6 months? For example, upper and lower motor neurone lesions may cause an ataxic gait, in which coordination and balance are impaired. These patients are more likely to develop hamstring or calf muscle injury due to poor flexibility – the so-called weekend warrior. All registration fields are required. a thrombosis or blood clot (deep vein thrombosis [DVT]), Angiotensin-converting enzyme (ACE) inhibitors, Central, crushing pain that radiates into the arms and jaw. 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. Detailed 4. What do you smoke – cigarettes, cigars, a pipe? The clinician must therefore be… For example, repeatedly exceeding the recommended daily dosage of vitamins A and D supplements may lead to ectopic calcification in tendon, muscle and periarticular tissue. Amphetamines, like many mood stimulants, have a vasoconstrictive effect. Examples of how to use “social history” in a sentence from the Cambridge Dictionary Labs Insect stings are also an important cause of anaphylactic fatality. 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. Cigarette smoking: Determine the number of packs smoked per day and the number of years this has occurred. may email you for journal alerts and information, but is committed Treatment may fail or cause the patient’s presenting condition to worsen because inadequate history taking has prevented accurate diagnosis of the presenting foot complaint. Diagnosis: Traumatic arthritis. For a new patient or consult, the clinician might say, "The past medical history shows that she has longstanding hyperllipidemia. Past medical, family, and social history (PFSH) A chief complaint is required for all levels of charting. 5.1). A pedigree chart may be used to record details of major illnesses and lower limb problems of the immediate family (Fig. Heavy alcohol consumption can affect the peripheral sensation, immune response, postoperative wound healing and the metabolism of local anaesthetics, as well as having implications for treatment compliance. Wolters Kluwer Health Obesity is associated with recalcitrant heel pain and other postural symptoms. 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. The item(s) has been successfully added to ", This article has been saved into your User Account, in the Favorites area, under the new folder. Small plaques of brown lipid under the eyes, seen in hyperlipidaemia, are associated with atherosclerosis. The diagnosis in a patient presenting with difficulty walking will be influenced by a positive family history of a condition such as these. patient’s medical history, inappropriate or unsafe treatment may be provided. 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 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. 30 mins. A fertilised female, gaining access to human skin, burrows beneath the surface where it becomes engorged with blood. Diagnosis: Congestive heart failure. The types of surface that the patient stands and walks on during the day can be exciting factors. With some types of treatment patients are required to reduce their activity level to a minimum, change dressings or administer treatments at home. 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. More than four units of alcohol per day is noteworthy. In such circumstances the patient should be informed that a second opinion is recommended. A history of cardiovascular disease should be taken with respect to systemic, peripheral and haematological disease states, followed up by a review of symptomatology. 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). This includes his or her age, gender, race, height, weight, current residential address and previous addresses. The social history in a medical history report needs to add if the patient has any sort of tobacco, alcohol or caffeine addiction. Syncope (fainting) is a transient loss of consciousness. Other examples of adverse drug reactions are listed in Table 5.1. Examination revealed a hyperpronatory foot type. social history. Hypothyroidism will lead to a loss of hair from the outer third of the eyebrows, baldness, and coarse, thickened facial skin. Having recorded disease states of which the patient is aware, enquire further about any systemic cardiovascular symptoms. For more information, please refer to our Privacy Policy. We must role-model how to take a social history for our trainees and peers. Patients with. For example, upper and lower motor neurone lesions may cause an ataxic gait, in which coordination and balance are impaired. 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. A 27-year-old female sales executive attended the clinic with heel pain. 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 … Social factors can be a major hindrance for patients to be healthy. Certain rhythms such as ventricular tachycardia predispose to cardiac arrest. “So how is your son doing in college?” “Did you plant a garden again this year?”. Originally a native of the New World, it is now widely disseminated in Africa and Asia. Other less-specific systemic cardiac. This will help the Doctors to decide on the course of treatment. Cardiac disease such as arrhythmias and aortic stenosis can cause syncope by decreasing the cerebral blood supply. 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. 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. The patient was subsequently prescribed stretching exercises and cortisone injections. Introduction 2. In the case of surgical treatment the practitioner must establish who is going to transport the patient to and from surgery and who is going to assist them through the immediate postoperative recovery period. Expanded Problem Focused 3. Adequate history taking will identify those patients who have previously developed adverse reactions. 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. Your message has been successfully sent to your colleague. Example of a Complete History and Physical Write-up Patient Name: Unit No: Location: Informant: patient, who is reliable, and old CPMC chart. Alcohol consumption is generally measured in units. 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. Practitioners should routinely take their patients’ blood pressure, not least because the stress caused by treatment or examination may provoke a clinical emergency in a patient with uncontrolled hypertension. Long-term or heavy use of tobacco can affect wound healing due to the immediate vasoconstrictive effect of nicotine as well as the long-term effects on increased platelet adhesiveness and atherosclerosis. 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. In medicine, a social history (abbreviated "SocHx") is a portion of the medical history (and thus the admission note) addressing familial, occupational, and recreational aspects of the patient's personal life that have the potential to be clinically significant. Medical Summary Reports. The following questions will reveal important information about the patient’s general health: • Are you under the doctor or consultant for any treatment currently? Social history: smoking, alcohol, recreational drugs, accommodation and living arrangements, marital … your express consent. Some error has occurred while processing your request. iodine allergy) or dressings (e.g. Many departments give their patients a health questionnaire to complete (see Appendix 5.1). transient ischaemic attacks) or routine screening reveals a diastolic blood pressure above 90 mmHg. Before history taking begins, the practitioner will gain some impressions about the patient’s current health status from simple observation. Bare concrete floors will exacerbate chilblains, whereas patients whose occupation involves standing on ladders will often suffer from chronic medial longitudinal arch pain. The patient should then be asked: • Have you been off work due to illness for more than 1 week in the past 6 months? The approach outlined in this chapter forms the basis of a holistic approach to patient care. 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. 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. 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. “My dog becomes visibly agitated and starts barking after smelling my breath when I'm getting sick,” she offered quickly when asked. 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. When multiplied this is referred to as "pack years." This can be sent to the patient before the initial visit or, more commonly, before they see the practitioner again. The systems enquiry involves asking questions that will seem, to the patient, to be quite unrelated to the lower limb problem. Data is temporarily unavailable. All the body systems are worked through in a set order, which can be remembered using the acronym ‘CRAGCEL’ (see Box 5.1). 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. The range of motion of the joint was reduced, with painful crepitus evident on dorsiflexion. Thankfully, fatal anaphylaxis is rare. This may be followed by a profound drop in blood pressure and life-threatening cardiovascular depression. Patients should be observed from the moment they enter the consulting room. The social history has fallen into disrepair. Pulmonary oedema and shortness of breath are, therefore, signs and symptoms of left-sided heart failure. 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. 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. For a new patient or consult, the clinician might say, "The past medical history … 2008;359:2748–2751. In such circumstances oxygen must be administered to support the patient. An illustrative poem or short work of literature can be incorporated into morning report or teaching rounds. A collection of interactive medical and surgical clinical case scenarios to put your diagnostic and management skills to the test. The nature of the work should be determined (what they actually do) and special footwear requirements should be noted. A systematic approach to history taking will ensure that the practitioner covers all relevant areas in the enquiry process. _____ Birth/ Delivery: Was the child full term? 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. 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. When an individual sensitised in this way is exposed on a second occasion to the allergen, the allergen combines with the IgE antibodies on the surface of the mast cells. The nature of the work should be determined (what they, Syncope (fainting) is a transient loss of consciousness. Depending on the PC it may also be pertinent to find out whether the patient drives, e.g. Please try again soon. It is characterised by inflammatory lesions of connective tissue structures, especially of the heart and blood vessels, and predisposes to bacterial endocarditis. Arch Intern Med. 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. Findings recorded with this system (Box 5.1) will determine the need for further clinical or laboratory investigation and indicate the patient’s suitability for a range of treatments. The history includes 4 elements: 1. The use of questionnaires gives patients time to consider their answers and reduces the time spent in taking a medical history during the consultation. One unit of alcohol is equivalent to one glass of wine, a single measure of spirits or half a pint of beer. Information about the patient’s previous and current drug therapy can provide useful information about the patient’s health. This may manifest clinically as vertebral collapse, leading to spinal deformity and possible neural compression. Point tenderness at the origin of the medial band of the plantar fascia was elicited. Lippincott Journals Subscribers, use your username or email along with your password to log in. The patient’s facial appearance and expression is also of interest to the practitioner. Hospitalisations for operations or injuries should be recorded and any complications noted (Case history 5.1). Cf Family history. 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. 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. For information on cookies and how you can disable them visit our Privacy and Cookie Policy. H-LABOR is a daily email-based discussion group formed in 1993 that reaches over a … Hypersensitivity reactions to medicaments (e.g. 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. Patients with chronic foot disorders may shuffle rather than stride because a propulsive gait could cause more pain. 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. 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. If the exposure to the allergen is systemic, hypotension, bronchiole constriction, laryngeal oedema, swelling of the tongue, urticaria, vomiting and diarrhoea may follow. Please enable scripts and reload this page. Individuals may be placed at risk by certain treatments, drugs or procedures that are usually considered routine. For some of the time in India he walked around barefoot and recalls occasionally having to remove splinters and small stones from his sole. 800-638-3030 (within USA), 301-223-2300 (international) In particular, recent travel to tropical countries and details of any foot injuries sustained while walking barefoot should be recorded (Case history 5.3). 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. The systems enquiry 4. This may manifest clinically as vertebral collapse, leading to spinal. The pain was aching in nature, severe and worse on exercise. (Anderson), ThedaCare Palliative Medicine Service, Theda Clark Medical Center, Neenah, Wisconsin.(Schiedermayer). 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. 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. 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.