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Determining a past medical history can help establish essential background to the patient’s health (Lloyd and Craig, 2007). While helping to generate a baseline for the patient’s health it also highlights potential diagnoses that may have been overlooked. It is this author’s experience that patients, when asked open questions regarding their past medical history, associate recent and life limiting illnesses as being relevant. This encounter was no different, the patient only reported lower limb arthritis and recent shingles. Consequently it was necessary to utilise the JAMTHREADSCa aide memoire to establish a history of COPD, breast cancer and hyperlipidaemia (Cupples 2011). The patient denied any surgical history. Investigation into the patient’s drug history can help to identify possible pathology or clinical signs related to pharmacological causes (Fitzgerald, 2009). The patient reported good adherence and a recent addition of Amitriptyline. She denied other medication use and reported no known allergies, drug or otherwise.
Understanding a patient’s social and family background is essential to providing effective and complete care (Rahman and Tasnim, 2007). Focussed questioning revealed a smoking history of 30 pack years, having stopped 5 years prior, retired from a clerical job, lives with her son and is now housebound. She additionally reported that her recent shingles had limited her day to day activities. Questions regarding her family history were inconclusive as specific details were not known, a frustration as it forms a fundamental part of a patient’s medical history (Alspach, 2011). The history taking was completed with a review of systems (RoS) that failed to reveal additional symptoms despite considerable probing. Jenkins (2013) recognises that a RoS enables a clinician to provide a holistic patient assessment while simultaneously being comprehensive and less susceptible to errors.