(Box 2.1). Each answer increases or decreases the probability
of a particular diagnosis and excludes others.
In the following example, the patient is a 65-year-old male
smoker. His age and smoking status increase the probability
of certain diagnoses related to smoking. A cough for 2 months
2.1 Examples of terms used by patients that should be clarified
Patient’s term Common underlying problems Useful distinguishing features
Allergy True allergy (immunoglobulin E-mediated reaction) Visible rash or swelling, rapid onset
Intolerance of food or drug, often with nausea or
Predominantly gastrointestinal symptoms
Indigestion Acid reflux with oesophagitis Retrosternal burning, acid taste
Site and nature of discomfort:
Epigastric, relieved by eating
Arthritis Joint pain Redness or swelling of joints
Immobility due to prior skeletal injury Deformity at site
Catarrh Purulent sputum from bronchitis Cough, yellow or green sputum
Infected sinonasal discharge Yellow or green nasal discharge
Nasal blockage Anosmia, prior nasal injury/polyps
Fits Transient syncope from cardiac disease Witnessed pallor during syncope
Epilepsy Witnessed tonic/clonic movements
Abnormal involuntary movement No loss of consciousness
Dizziness Labyrinthitis Nystagmus, feeling of room spinning, with no other neurological deficit
Syncope from hypotension History of palpitation or cardiac disease, postural element
Cerebrovascular event Sudden onset, with other neurological deficit
12 • General aspects of history taking
Having clarified the presenting symptoms, prompt for any
more associated features, using your initial impression of the
likely pathology (lung cancer or chronic respiratory infection) to
Do you ever feel short of breath with your cough?
How has your weight been? (Seeking additional
confirmation of serious pathology)
I’ve lost about a stone since this started.
The questions required at this point will vary according to the
system involved. A summary of useful starting questions for each
system is shown in Box 2.3. Learn to think, as you listen, about
the broad categories of disease that may present and how these
relate to the history, particularly in relation to the onset and rate
of progression of symptoms (Box 2.4).
To complete the history of presenting symptoms, make an
initial assessment of how the illness is impacting on the life of
your patient. For example, breathlessness on heavy exertion
may prevent a 40-year-old builder from working but would have
much less impact on a sedentary retired person. ‘Can you tell
me how far you can walk on a good day?’ is a question that
can help to clarify the normal level of functioning, and ‘How
has this changed since you have been unwell?’ can reveal
disease impact. Ask if the person undertakes sports or regular
exercise, and if they have modified these activities because
Have you ever coughed up any blood? (Closed
When did it first appear and how often does it
Oh, most days. I’ve noticed it for over a month.
How much? (Closed question, clarifying the
Is it pure blood or mixed with yellow or green
Just streaks of blood in clear phlegm.
Chest pain: Can you tell me about the chest pains?
Well, they’re here on my side (points) when I cough.
Does anything else bring on the pains? (Open,
Taking a deep breath, and it really hurts when I cough
Pain is a very important symptom common to many areas of
practice. A general scheme for the detailed characterisation of
2.2 Characteristics of pain (SOCRATES)
• Somatic pain, often well localised, e.g. sprained ankle
• Visceral pain, more diffuse, e.g. angina pectoris
• Speed of onset and any associated circumstances
• Described by adjectives, e.g. sharp/dull, burning/tingling, boring/
stabbing, crushing/tugging, preferably using the patient’s own
description rather than offering suggestions
• Referred by a shared neuronal pathway to a distant unaffected site, e.g.
diaphragmatic pain at the shoulder tip via the phrenic nerve (C3, C4)
• Visual aura accompanying migraine with aura
• Numbness in the leg with back pain suggesting nerve root irritation
Timing (duration, course, pattern)
• If episodic, duration and frequency of attacks
• If continuous, any changes in severity
Exacerbating and relieving factors
• Circumstances in which pain is provoked or exacerbated, e.g. eating
• Specific activities or postures, and any avoidance measures that
have been taken to prevent onset
• Effects of specific activities or postures, including effects of
medication and alternative medical approaches
• Difficult to assess, as so subjective
• Sometimes helpful to compare with other common pains, e.g.
• Variation by day or night, during the week or month, e.g. relating to
2.3 Questions to ask about common symptoms
Cardiovascular Do you ever have chest pain or tightness?
Do you ever wake up during the night feeling
Have you ever noticed your heart racing or
Respiratory Are you ever short of breath?
Have you had a cough? If so, do you cough
Have you ever coughed up blood?
Gastrointestinal Are you troubled by indigestion or heartburn?
Have you noticed any change in your bowel habit
Have you ever seen any blood or slime in your
Genitourinary Do you ever have pain or difficulty passing urine?
Do you have to get up at night to pass urine? If
Have you noticed any dribbling at the end of
Have your periods been quite regular?
Musculoskeletal Do you have any pain, stiffness or swelling in
Do you have any difficulty walking or dressing?
Endocrine Do you tend to feel the heat or cold more than
Have you been feeling thirstier or drinking more
Neurological Have you ever had any fits, faints or blackouts?
Have you noticed any numbness, weakness or
clumsiness in your arms or legs?
along with any significant adverse effects, in a clear format (Box
2.5). When drugs such as methadone are being prescribed
for addiction, ask the community pharmacy to confirm dosage
and also to stop dispensing for the duration of any hospital
Half of all patients do not take prescribed medicines as directed.
Patients who take their medication as prescribed are said to be
adherent. Concordance implies that the patient and doctor have
negotiated and reached an agreement on management, and
adherence to therapy is likely (though not guaranteed) to improve.
Ask patients to describe how and when they take their
medication. Give them permission to admit that they do not
take all their medicines by saying, for example, ‘That must be
Ask if your patient has ever had an allergic reaction to a medication
or vaccine. Clarify exactly what patients mean by allergy, as
intolerance (such as nausea) is much more common than true
allergy. Drug allergies are over-reported by patients: for example,
only 1 in 7 who report a rash with penicillin will have a positive
penicillin skin test. Note other allergies, such as foodstuffs or
pollen. Record true allergies prominently in the patient’s case
records, drug chart and computer records. If patients have had
a severe or life-threatening allergic reaction, advise them to wear
an alert necklace or bracelet.
Ask all patients who may be using drugs about non-prescribed
drugs. In Britain about 30% of the adult population have used
Past medical history may be relevant to the presenting symptoms:
for example, previous migraine in a patient with headache, or
haematemesis and multiple minor injuries in a patient with
suspected alcohol abuse. It may reveal predisposing past or
underlying illness, such as diabetes in a patient with peripheral
vascular disease, or childhood whooping cough in someone
presenting with bronchiectasis.
The referral letter and case records often contain useful
headlines but the patient is usually the best source. These
questions will elicit the key information in most patients:
• What illnesses have you seen a doctor about in the past?
• Have you been in hospital before or attended a clinic?
• Have you had any operations?
• Do you take any medicines regularly?
This follows naturally from asking about past illness. Begin by
checking any written sources of information, such as the drug list
on the referral letter or patient record. It is useful to compare this
with the patient’s own recollection of what they take. This can
be complicated by patients’ use of brand names, descriptions
of tablet number and colour and so on, which should always
be translated to generic pharmaceutical names and quantitative
doses for the patient record. Ask about prescribed drugs and
other medications, including over-the-counter remedies, herbal
and homeopathic remedies, and vitamin or mineral supplements.
Do not forget to ask about inhalers and topical medications, as
patients may assume that you are asking only about tablets.
Note all drug names, dosage regimens and duration of treatment,
2.4 Typical patterns of symptoms related to disease causation
Disease causation Onset of symptoms Progression of symptoms Associated symptoms/pattern of symptoms
Infection Usually hours, unheralded Usually fairly rapid over hours
Fevers, rigors, localising symptoms, e.g. pleuritic pain and
Inflammation May appear acutely Coming and going over weeks
Nature may be multifocal, often with local tenderness
Metabolic Very variable Hours to months Steady progression in severity with no remission
Malignant Gradual, insidious Steady progression over weeks
Toxic Abrupt Rapid Dramatic onset of symptoms; vomiting often a feature
Trauma Abrupt Little change from onset Diagnosis usually clear from history
Vascular Sudden Stepwise progression with
Rapid development of associated physical signs
Degenerative Gradual Months to years Gradual worsening with periods of more acute deterioration
Drug Dose Duration Indication Side-effects/patient concerns
Aspirin 75 mg daily 5 years Started after myocardial infarction Indigestion
Atenolol 50 mg daily 5 years Started after myocardial infarction Cold hands (?adherence)
Co-codamol (paracetamol + codeine) 8 mg/500mg, up to
4 weeks Back pain Constipation
Salbutamol MDI 2 puffs as necessary 6 months Asthma Palpitation, agitation
14 • General aspects of history taking
disorder. A further complication is that some illnesses, such as
asthma and diseases caused by atheroma, are so common in
the UK population that their presence in family members may
not greatly influence the risk to the patient.
Document illness in first-degree relatives: that is, parents,
siblings and children. If you suspect an inherited disorder such
as haemophilia, construct a pedigree chart (Fig. 2.1), noting
whether any individuals were adopted. Ask about the health of
other household members, since this may suggest environmental
No medical assessment is complete without determining the
social circumstances of your patient. These may be relevant to
the causes of their illness and may also influence the management
and outcome. Establish who is there to support the patient by
asking ‘Who is at home with you, or do you live alone?’ For
those who live alone, establish who is their next of kin and who
visits regularly to support them. Check if your patient is a carer
for someone vulnerable who may be at risk due to your patient’s
illness. Enquire sensitively if the patient is bereaved, as this can
have profound effects on a patient’s health and wellbeing.
Next establish the type and condition of the patient’s housing
and how well it suits them, given their symptoms. Patients with
severe arthritis may, for example, struggle with stairs. Successful
management of the patient in the community requires these
Among other things, tobacco use increases the risk of obstructive
lung disease, cardiac and vascular disease, peptic ulceration,
illegal or non-prescribed drugs (mainly cannabis) at some time.
Useful questions are summarised in Box 2.6.
Start with open questions, such as ‘Are there any illnesses that
run in your family?’ Follow up the presenting symptoms with
a question like ‘Have any of your family had heart trouble?’
Single-gene inherited diseases are relatively uncommon in clinical
practice. Even when present, autosomal recessive diseases such
as cystic fibrosis usually arise in patients with healthy parents
who are unaffected carriers. Many other illnesses are associated
with a positive family history but are not due to a single-gene
2.6 Non-prescribed drug history
• How long have you been taking drugs?
• Have you managed to stop at any time? If so, when and why did
• What symptoms do you have if you cannot get drugs?
• Do you ever inject? If so, where do you get the needles and
• Do you ever share needles, syringes or other drug-taking
• Do you see your drug use as a problem?
• Do you want to make changes in your life or change the way you
• Have you been checked for infections spread by drug use?
identified as the index case, around whom the pedigree chart is constructed.
are usually absent. These two causes of absent sounds are
readily distinguished by percussion, which will be resonant with
pneumothorax and completely dull over pleural fluid.
Remember to wear the stethoscope with the ear pieces facing
forwards to align them with your auditory canal. Normal breath
sounds are relatively quiet, so the greater area of contact offered
by the diaphragm is usually well adapted to chest auscultation.
The two common exceptions are in patients with:
• A cachectic chest wall with sunken intercostal spaces,
where it may be impossible to achieve flat skin contact
• A hairy chest wall, where movement of chest hairs against
the diaphragm are easily mistaken for lung crackles. In
these situations, use the stethoscope bell instead to listen
As with percussion, the absolute volume and character of breath
sounds in individuals are greatly affected by the thickness,
muscularity and fat content of the chest wall. The symmetry of
sounds is therefore the key feature.
• Auscultate the apices, comparing right with left, and
changing to the bell if you cannot achieve flat skin contact
• Ask the patient to take repeated slow, deep breaths in
and out through their open mouth. Auscultate the anterior
chest wall from top to bottom, always comparing mirror
image positions on right and left before moving down.
• Use the same sequence of sites as for percussion (see
Fig. 5.16B and C). Do not waste time by listening to
repeated breath cycles at each position, unless you
suspect an abnormality and wish to check.
• Note whether the breath sounds are soft and muffled,
absent, or loud and harsh (bronchial, like those heard over
the larynx). Seek and note any asymmetry and added
sounds (see later), deciding which side is abnormal.
• Auscultate the lateral chest wall in the mid-axillary line,
again comparing right with left before changing level.
normal lung is almost all air. Resonance on percussion together
with unilateral absent breath sounds indicates pneumothorax.
To understand chest auscultation it is necessary to understand
the origin of breath sounds. The tracheobronchial tree branches
23 times between the trachea and the alveoli. This results in an
exponential rise in the number of airways and their combined
cross-sectional area moving towards the alveoli. During a maximal
breath in and out, the same vital capacity (about 5 L of air in
healthy adults) passes through each generation of airway. In
the larynx and trachea, this volume must all pass through a
cross-sectional area of only a few square centimetres and therefore
flow rate is fast, causing turbulence with vibration of the airway
wall and generating sound. In the distal airway, the very large
total cross-sectional area of the multitude of bronchioles means
that 5 L can easily pass at slow flow rates, so flow is normally
virtually silent. The harsh ‘bronchial’ sound generated by the
major airways can be appreciated by listening with the diaphragm
of the stethoscope applied to the larynx (try this on yourself).
Most of the sound heard when auscultating the chest wall
originates in the large central airways but is muffled and deadened
by passage through overlying air-filled alveolar tissue; this, together
with a small contribution from medium-sized airways, results in
‘normal’ breath sounds at the chest wall, sometimes termed
‘vesicular’. When healthy, air-filled lung becomes consolidated
by pneumonia or thickened and stiffened by fibrosis, sound
conduction is improved, and the centrally generated ‘bronchial’
breath sounds appear clearly and loudly on the overlying chest
wall. In the same way, with soft speech (‘say one, one, one’),
the laryngeal sounds are muffled by healthy lung but heard
clearly and loudly at the chest wall overlying consolidation and
fibrosis, due to improved conduction of major airway sounds
When there is lobar collapse caused by a proximal bronchial
obstruction, the signs are different from those in simple
consolidation. The usual findings are diminished expansion,
sometimes with chest asymmetry due to loss of volume, dullness
to percussion over the collapsed lobe, and reduced breath sounds
When the lung tissue is physically separated from the chest
wall by intervening air (pneumothorax) or fluid (pleural effusion),
sound conduction is greatly impaired and the breath sounds
Fig. 5.16 Percussion of the chest. A Technique. B Anterior and lateral sites. C Posterior sites.
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