The history

An appropriate history will allow the recognition of certain risk factors that may foreshadow future disease. Though established patients will have a previously acquired database, their history should be reviewed and updated. It is recommended that the following items be included in history taking in the appropriate age groups.

Family history. In particular, cardiovascular disease, some cancers (breast, bowel, melanoma with dysplastic naevi), diabetes, asthma, genetic disorders and bowel disease will alert the doctor to specific risk factors (and psychological factors) for these patients.

Suicide and accidents. Consider the risk factors predisposing to suicide and accidents, which are the major preventable causes of death in children and young adults.

Substance abuse. Tobacco and alcohol are the major causes of preventable death in adults, although other drugs contribute to a lesser extent. Counselling by general practitioners, about smoking in particular, has been shown to be effective.

Exercise and nutrition. These factors have a role to play in preventing cardiovascular disease and to a lesser extent in blood pressure control, cancer, diabetes and constipation. They have an even greater role to play in improving general well-being and preventing morbidity.

Occupational health hazards. Consider these in working adults, as occupational health hazards can significantly contribute to morbidity and mortality, e.g. exposure to toxic substances, unsafe work practices.

Physical functioning, home conditions and social supports. Consider these in elderly people, as physical function and social supports are of crucial importance in determining whether they can care for themselves—intervention can prevent accidents and death.

Sexuality/contraception. Sexually transmitted diseases are all preventable, as are unwanted pregnancies. Opportunities should be sought to ask young people, in particular, about their sexuality, and to counsel them. The question 'Do you have any concerns about sex?' is very useful in this context.

Osteoporosis. Osteoporosis affects nearly a third of all postmenopausal women, most of whom suffer osteoporotic fractures. Fractures of the femoral neck have a particularly poor prognosis, with up to a third of these women dying within 6 months, and many more requiring continuing nursing home care. Bone loss accelerates at the time of the menopause, and can be reduced by hormone replacement therapy.

Women at risk of osteoporosis are short, slim, Caucasian; they drink coffee and alcohol, smoke, eat a high-protein and high-salt diet, and don't exercise.

Masquerades in general practice. It is worth considering the 'masquerades' (Chapter 15 , Tables 15.4 and 15.5), which may present as undifferentiated illness, as a means of following the important medical principle of early detection of disease: engendering a certain awareness. Primary masquerades to consider are:

• depression

diabetes mellitus

drug problems

• thyroid disorders, especially hypothyroidism

urinary tract infection

• vertebral (spinal) dysfunction

Hypothyroidism has been estimated to exist in up to 15% of women aged 60 and above, and searching for clues may elicit subtle symptoms and signs previously attributed to ageing.

Relationships and psychosocial health. Consider the mental health of patients, particularly the elderly, by enquiring about how they are coping with life, how they are coping financially, about their peace of mind and how things are at home. Focus on the quality of their close relationships, e.g. husband-wife, father-son, mother-daughter, employer-employee. Enquire about losses in their life, especially family bereavements.

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