History And Clinical Examination The History

A complete and accurate history of ED is essential for a reliable diagnosis. Communication about this issue can be loaded with cultural, religious, secular, and personal connotations and therefore the problem of ED must be approached with the right attitude. The clinician should at least appear to be open, sensitive, respectful, confident, and nonjudgemental. Questions should be unambiguous. Language must be clear and uninhibited by complex medical terminology. Never make an assumption about what the patient is trying to say. Use open questions to elicit the bulk of the information, and clarify issues by asking closed questions and by reflecting ideas back to ensure that you have understood what the patient means. It is also important to understand the patient's perspective and expectations. The media in particular can distort someone's point of view and myths and misunderstandings may need to be undone (only if you are sure yourself!). Keep in mind the pathophysiology of ED, and ask relevant questions about each system.

Start with general information about the man's life and work. Employment related stress and relationship difficulties are often involved in the etiology. Ask about the problem, its duration, frequency, and specifics such as whether the erection can be elicited but not maintained (suggestive of a veno-occlusive disorder). Ask about his past medical history and current treatments. As we have already seen, an elderly diabetic is in the highest risk group for ED. What is the patient's motivation for seeking help, and why now? There is sometimes a mismatch of expectation between the patient and his sexual partner. ED is often situational, occurring only in the presence of a partner, but the man may enjoy satisfactory masturbation and have spontaneous/nocturnal erections. Note that loss of nocturnal erections is a strong indicator of a physical problem, but can also be as a result of a major depressive disorder. Ask specific questions about other cardiovascular, neurological, and endocrinological symptoms. [For a more detailed description of neurological factors affecting ED refer to Lundberg et al. (15); for endocrinological factors refer to Heaton and Morales (16); for cardiological factors refer to Jackson et al. (17).] Does the man smoke or drink alcohol to excess or use recreational drugs? Some questions may be asked if the clinician suspects a specific etiology. For instance, is there a psychological reason, such as hidden guilt, about having sex outside the relationship, whether it be with a woman or another man? Gay sex is still a taboo subject for many, and the apparent inability of the society to come to terms with it can leave an individual feeling guilty or anxious about his sexual preference. Alternatively, there may be a fear of getting a woman pregnant, or contracting/passing on a sexually transmitted infection?

On occasion, a man may alter his history over time and reveal more information. He may have several issues that have prevented him from being totally frank. Being nonjudgemental will smoothen the doctor-patient relationship and result in a better consultation for both the professional and the patient.

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