Past, Family, Social, Drug History

and Systemic Enquiry

 Objectives
At the end of this session the student should be able to:
- How medical history will be taken.
- What we mean by past, family, social and systemic review
and how they will be taken.
- Ask about current and long term patient’s medications.
- To note down the name, dose, duration and side effects of
drugs.
- To know the compliance, adherence and concordance of the
patient to the drugs.
Past Medical History
• Past medical history may be relevant to the
presenting complaint: e.g. previous angina in a
patient with chest pain, or haematemesis and
a past history of multiple minor injuries, which
raise the possibility of alcohol abuse.
Ask About
• Medical conditions
• Recent hospital admissions
• Admissions to the intensive care unit
 Specific Conditions To Ask About 
• Use simple terms when asking questions, rather than
medical terms such as ‘hypertension' or
‘dyslipidaemia'.
• Asthma
• Diabetes
• Heart disease
• High blood pressure
• High cholesterol
• Cancer
 Sources of Past Medical History
• The patient
• Collateral - from family or friends
• The patient's file - especially discharge
summaries
• Other hospitals - especially discharge
summaries or transfer letters
• The patient's GP
• Letters from specialists
 Disease History
• These are examples of questions to ask to
further ellucidate the course of each of the
patient's medical conditions.
 Diagnosis
• When they were diagnosed
• Who diagnosed the condition
• How it was diagnosed - clinically, based on
blood tests, imaging or invasive investigations
• Underlying cause (if known) - e.g. diabetic
nephropathy as a cause of chronic kidney
disease, or alcohol as a cause of cirrhosis
History of Systemic Review
(Enquiry)
 Review of Systems
• Documents presence or absence of common
symptoms related to each major body system
 General
• Usual weight, recent weight change, any
clothes that fit more tightly or loosely than
before.
• Weakness, fatigue, fever.
 Skin
Rashes, lumps, sores, itching, dryness, color
change, changes in hair or nails.
 Head, Eyes, Ears, Nose, Throat
(HEENT)
• Head: Headache, head injury,dizziness, light
headedness.
• Eyes: Vision, glasses or contact lenses, last
examination, pain, redness, excessive tearing,
double vision, blurred vision, spots, specks,
flashing lights, glaucoma, cataracts.
• Ears: Hearing, tinnitus, vertigo, earaches,
infection, discharge. If hearing is decreased,
use or nonuse of hearing aids.
• Nose and sinuses: Frequent colds, nasal
stuffiness, discharge, or itching, hay fever,
nosebleeds, sinus trouble.
• Throat (or mouth and pharynx): Condition of
teeth, gums, bleeding gums, dentures, if any,
and how they fit, last dental examination, sore
tongue, dry mouth, frequent sore throats,
hoarseness.
 Neck
• Lumps, “swollen glands,” goiter, pain, or
stiffness in the neck.
 Respiratory
• Cough, sputum (color, quantity), hemoptysis,
dyspnea, wheezing.
 Cardiovascular
• Heart trouble, high blood pressure, rheumatic
fever, heart murmurs, chest pain or
discomfort, palpitations, dyspnea, orthopnea,
paroxysmal nocturnal dyspnea, edema.
 Gastrointestinal
• Trouble swallowing, heartburn, appetite,
nausea, bowel movements, color and size of
stools, change in bowel habits, rectal bleeding
or black or tarry stools, hemorrhoids,
constipation, diarrhea.
• Abdominal pain, food intolerance, excessive
belching or passing of gas. Jaundice, liver or
gallbladder trouble, hepatitis.
 Urinary
• Frequency of urination, polyuria, nocturia,
urgency, burning or pain on urination,
hematuria, urinary infections, kidney stones,
incontinence
 Musculoskeletal
• Muscle or joint pains, stiffness, arthritis, gout,
and backache.
 Neurologic
• Fainting, blackouts, seizures, weakness,
paralysis, numbness or loss of sensation,
tingling or “pins and needles,” tremors or
other involuntary movements.
 Hematologic
• Anemia, easy bruising or bleeding, past
transfusions and/or transfusion reactions.
 Endocrine
• Thyroid trouble, heat or cold intolerance,
excessive sweating, excessive thirst or hunger,
polyuria, change in glove or shoe size.
Family history
• The presenting complaint may direct you to a
particular line of enquiry: for example, 'Is
there any history of heart disease in your
family?
• Document illness in first-degree relatives: that
is, parents, siblings and children.
Social history
• Who else is there at home?’ Job. Marital
status. Spouse’s job and health.
• Housing—any stairs at home? Who visits—
relatives, neighbours, GP, nurse?
• Ask about occupation, hobbies, sport,
exercise, and ethnic origin.
• Tactfully ask about alcohol, tobacco, and
recreational drugs. How much? How long?
When stopped?
• Quantify smoking in terms of pack-years: 20
cigarettes/day for 1 year equals 1 pack-year.
 Drug history
• Ask about prescribed drugs and any other
medications.
• over-the-counter remedies and alternative
medicine treatments
• herbal or homeopathic remedies
• laxatives, analgesics and vitamin/mineral
supplements
• Note the name:
of each drug
dose
dosage regimen
duration of treatment
significant side-effects.
• Compliance
• concordance
• adherence
 Drug allergies/reactions
• Ask if your patient has ever had an allergic
reaction to medication.
• Clarify exactly what patients mean by allergy.
• Enquire particularly before prescribing an
antibiotic, especially penicillin.
• Ask about other allergies
 Example of a drug history
Drug Dose Duration Indication Side-effects,
patient
concern

Aspirin 75 mg daily 5 years Started after  

myocardial
infarction
Amitriptyline 25 mg at night 6 months Poor sleep Feels drowsy in
morning

Atenolol 50 mg daily 5 years Started after Causes cold

myocardial hands (?
infarction compliance

Codydramol Up to 8 tabs 4 weeks Back pain Causes

(paracetamol + daily constipation
dihydrocodeine)
 Clarifying questions in the drug
history
• Tell me all the drugs or medicines that you
take.
• Have any been prescribed from another clinic,
doctor or dentist?
• Do you buy any yourself from a pharmacy?
• Are you sure you have told me about all
tablets, capsules and liquid medicines?
• What about inhalers, skin creams or patches,
suppositories, or tablets to suck?
• Were you taking any medicines a little while
ago but stopped recently?
• Do you ever take any medicines prescribed for
other people, such as your spouse?
• Do you use herbal or other complementary
medicines?
References
• Hutchison’s Clinucal Methods, Robert
Hutchison’s. W.B. Saunders Company.
• Bates’ guide to physicalExamination & History
Taking, Lynn S. Bickley and peter G., M. D.
Szilagyi. Lippincott Williams & Wiklkins.
• Macleod’s cliinical examination, 12th edition.
Thank You