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

or days

Fevers, rigors, localising symptoms, e.g. pleuritic pain and

cough

Inflammation May appear acutely Coming and going over weeks

to months

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

to months

Weight loss, fatigue

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

acute episodes

Rapid development of associated physical signs

Degenerative Gradual Months to years Gradual worsening with periods of more acute deterioration

2.5 Example of a drug history

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

8 tablets daily

4 weeks Back pain Constipation

Salbutamol MDI 2 puffs as necessary 6 months Asthma Palpitation, agitation

MDI, metered-dose inhaler.

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

risks to the patient.

Social history and lifestyle

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

issues to be addressed.

Smoking

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.

Family history

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

• What drugs are you taking?

• How often and how much?

• How long have you been taking drugs?

• Have you managed to stop at any time? If so, when and why did