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
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