Comprehensive Patient History Research Articles

How to take a comprehensive patient history.

A significant proportion of diagnoses are made based on history taking, often alongside physical assessments and laboratory investigations. Taking a thorough patient history is fundamental for the accurate diagnosis and effective management of health conditions. This article outlines a step-by-step process for taking a comprehensive patient history and discusses the evidence for this procedure. • History taking is a structured but flexible process of gathering relevant information from patients to inform diagnosis and treatment. • Important communication skills for nurses when history taking include active listening, empathetic communication and cultural sensitivity. • By actively engaging the patient in a conversation about their health issues, the nurse facilitates their participation and autonomy. REFLECTIVE ACTIVITY: 'How to' articles can help to update your practice and ensure it remains evidence based. Apply this article to your practice. Reflect on and write a short account of: • How this article might improve your practice when taking a patient history. • How you could use this information to educate nursing students or colleagues on taking a patient history.

Unraveling the Enigma of Gossypiboma: A Series of 14 Cases Highlighting the Prevalence, Root Causes, and Outcomes in Resource-Limited Settings.

Gossypiboma or textiloma is the unintentional retention of textile material in a patient's body, often occurring during abdominal surgery and involving surgical sponges. The body may respond to this foreign body with an exudative inflammatory reaction or an aseptic fibrotic reaction, encapsulating the cotton material and forming a mass. This rare but dramatic event can lead to life-threatening complications, and due to legal and ethical concerns, few publications exist. There were no published papers regarding this issue in our nation (Yemen). This study aims to report the retained surgical sponges' cases and their associated factors in a resource-limited setting to improve prevention. A retrospective case series study was conducted at hospitals affiliated with Ibb University, Ibb, Yemen, between March 22, 2018, and May 12, 2024. The study included 14 cases of diagnosed and surgically confirmed retained surgical sponges. Data on demographic characteristics, type of operation, and risk factors were gathered and analyzed. Among 15,120 surgical procedures, there were 14 cases of retained surgical sponges with a prevalence rate of 0.09%. The mean age was 32.5±17.0 years, with 10 (71.4%) females and 4 (28.6%) males. Gynecological surgery was the most common causal procedure (n=7, 50.0%). The most common clinical presenting features were abdominal pain in 12 (85.7%), followed by infections and a systemic reaction in 9 (64.3%). The median symptom incubation time was 37 days. 11 (78.5%) patients underwent abdominal X-rays, and 13 (92.8%) had abdominal ultrasounds, with 4 (28.6%) X-rays and 5 (35.7%) abdominal ultrasounds being deemed non-diagnostic. An abdominal-pelvic CT scan was done on 11 (78.5%) individuals, with the results being diagnostic in 10 (71.4%) and non-diagnostic in one (7.1%). The leading causes for gossypiboma occurrence were prolonged surgical procedures > one hour and emergency in 7 (50.0%) cases, followed by multiple surgical team involvement and change in nursing staff during procedures in 5 (35.7%) cases. A gossypiboma or retained foreign body diagnosis can be achieved through comprehensive patient history, radiologist-surgeon interaction, understanding of risk factors, and familiarity with imaging patterns. Safety procedures should be robust and straightforward, and effective communication among surgical professionals can help minimize medical negligence and protect patients in chaotic situations.Furthermore, the surgeon should adhere to the standard prescribed method and report cases of retained surgical sponges.

A Hidden Cause of Hypertransaminasemia: Liver Toxicity Caused by Chelidonium Majus L.: Report of Two Cases of Herb-Induced Liver Injury and Literature Review.

In instances where individuals manifest elevated transaminase levels without a clearly discernible cause, a comprehensive patient history proves invaluable in unveiling latent triggers. In this report, we present 2 cases of herb-induced liver injury (HILI) characterized by severe hypertransaminasemia attributed to the consumption of Chelidonium majus L. (also known as greater celandine [GC]), an agent considered an alternative therapeutic remedy. Exploring the occurrence and range of clinical manifestations in HILI linked to Chelidonium majus L., while also investigating the potential triggers and predisposing factors for hepatotoxic reactions post Chelidonium majus L. usage, remains challenging due to the absence of definitive laboratory tests to identify the causative agent. Two case reports were detailed, and a systematic literature review using PubMed was conducted including published literature till March 2023. Moreover, a manual search of reference lists of pertinent articles was performed to identify any additional relevant missed publications. In the first case, a 64-year-old woman presented with jaundice, revealing a 1-month history of using GC capsules to manage gallstones. Diagnostic assessment identified HILI, gallstones, and choledocolithiasis, with transaminase levels exceeding 1000 IU/L. After discontinuing GC and receiving intravenous therapy with amino acids and phospholipids, the patient's condition significantly improved. Subsequently, she underwent endoscopic common bile duct stone removal and cholecystectomy. In the second case, a 66-year-old woman presented with elevated liver function test results discovered incidentally during musculoskeletal pain evaluation. Upon further questioning, the patient disclosed regular consumption of GC tea for "health promotion." Following intravenous therapy using amino acids and phospholipids, her transaminase levels returned to normal. The literature review identified 38 cases of HILI associated with GC preparations, primarily in adult women aged 27-77 years, with a predominant reporting location in Germany. Various forms of GC were used, with treatment durations ranging from 1 week to a year. Discontinuation of GC generally led to recovery in these cases. Chelidonium majus L., a potent herb often used in alternative medicine, has significant hepatotoxic potential, requiring physicians to be vigilant in cases of unexplained liver injury.

Revolutionizing Healthcare: AI-Driven Advances in EMR Management

The integration of artificial intelligence (AI) and blockchain technologies signifies a significant paradigm shift within the healthcare domain, unlocking novel pathways for transformation. Conventional healthcare infrastructures grapple with challenges such as disjointed patient data, manual prescription processes, and restricted access to complete medical records. In response to these issues, our initiative presents an innovative solution that harnesses the synergies of AI and blockchain to establish a state-of-the-art healthcare framework. At its core, our mission revolves around the creation of a decentralized ecosystem that reimagines how patient records are managed and prescriptions are handled. By seamlessly blending AI algorithms with blockchain technology, our system aims to tackle pivotal challenges in healthcare, including addressing gaps in data interoperability, ensuring prescription accuracy, and facilitating streamlined access to comprehensive patient information. The foundational elements of this framework include decentralized data storage, AI-guided prescription generation, consolidation of extensive patient histories, user-centric design, robust data security, compliance with privacy regulations, and a steadfast commitment to ethical considerations. This exploration delves deep into the obstacles confronting traditional healthcare systems, presenting a thorough problem statement. It articulates the objectives of our proposed system, providing a transparent roadmap for confronting these challenges head-on. As we progress towards achieving these objectives, our project envisions a metamorphosed healthcare landscape characterized by heightened precision in medical decision-making, increased patient engagement, and overall enhanced efficiency. This endeavor holds the potential to revolutionize healthcare practices, empower healthcare professionals, and elevate the patient experience by seamlessly harnessing the convergence of AI and blockchain technologies. Keywords: Artificial Intelligence (AI), Blockchain, Healthcare, Decentralized, Electronic Medical Record (EMR), comprehensive patient history consolidation.

Identifying key items to be addressed by non-clinical operators to manage out-of-hours telephone triage services for older adults seeking non-urgent unplanned care in Belgium: an e-Delphi study

BackgroundThis study aimed to achieve expert consensus regarding key items to be addressed by non-clinical operators using computer-software integrated medical dispatch protocols to manage out-of-hours telephone triage (OOH-TT) services for calls involving older adults seeking non-urgent unplanned care across Belgium.MethodsA three-part classic e-Delphi study was conducted. A purposive sample of experts specialized in out-of-hours unplanned care and/or older persons across Belgium were recruited as panelists. Eligibility criteria included experts with at least 2 years of relevant experience. Level of consensus was defined to be reached when at least 70% of the panelists agreed or disagreed regarding the value of each item proposed within a survey for the top 10 most frequently used protocols for triaging older adults. Responses were analyzed over several rounds until expert consensus was found. Descriptive and thematic analyses were used to aggregate responses.ResultsN = 12 panelists agreed that several important missing protocol topics were not covered by the existing OOH-TT service. They also agreed about the nature of use (for the top 10 most frequently used protocols) but justified that some modifications should be made to keywords, interrogation questions, degree of urgency and/or flowcharts used for the algorithms to help operators gain better comprehensive understanding patient profiles, medical habits and history, level of support from informal caregivers, known comorbidities and frailty status. Furthermore, panelists also stressed the importance of considering feasibility in implementing protocols within the real-world setting and prioritizing the right type of training for operators which can facilitate the delivery of high-quality triage. Overall, consensus was found for nine of the top 10 most frequently used protocols for triaging older adults with no consensus found for the protocol on triaging patients unwell for no apparent reason.ConclusionOur findings show that overall, a combination of patient related factors must be addressed to provide high quality triage for adults seeking non-urgent unplanned care over the telephone (in addition to age). However, further elements such as appropriate operator training and feasibility of implementing more population-specific protocols must also be considered. This study presents a useful step towards identifying key items which must be targeted within the larger scope of providing non-urgent out-of-hours telephone triage services for older adults seeking non-urgent unplanned care.

Neuropathic Pain

Neuropathic pain, caused by damage to the nervous system, presents a major challenge in clinical care due to its complex nature. This review focuses on the mechanisms and current treatment strategies for neuropathic pain, particularly in conditions such as diabetes and other chronic neurological disorders. Neuropathic pain often manifests as spontaneous pain, hyperalgesia, and allodynia. Diagnosis involves a comprehensive patient history, physical examination, and specialized tests. Although pharmacologic treatments such as anticonvulsants and antidepressants are common, their efficacy is often limited by side effects. Non-pharmacologic therapies, including physical therapy and neuromodulation, provide additional relief. Emerging treatments, like nerve growth factor inhibitors, show promise in early trials. Personalized medicine, incorporating genetic and molecular insights, could revolutionize future treatment approaches. Continued research into these mechanisms is crucial for improving patient outcomes.

Evaluation and significance of a digital assistant for patient history-taking and physical examination in telemedicine

Introduction Assisted history-taking systems can be used in provider-to-provider teleconsultations to task-shift the collection of evidence-based medical history and physical exam information to a frontline health worker. We developed such a task-shifting digital assistant, called ‘Ayu’, for nurses in rural India to collect clinical information from a patient and share it with a remote doctor to arrive at an accurate diagnosis and triage decision. Materials & Methods We evaluated the ability of the task-shifting digital assistant to collect a comprehensive patient history by using 190 standardized patient case studies and evaluating the information recall of the assistant by a skilled clinician. Following this, we tested the ability of nurses to use the system by training and evaluating the system’s accuracy when used by 19 nurses in rural Gujarat, India. We also measured the diagnostic and triage accuracy based on the generated history note. Finally, we evaluated the system’s acceptability by using the Technology Acceptance Model framework. Results Ayu could capture 65% of patient history information and 42% of physical exam information from patient case studies. When used by nurses, the mean accuracy of the generated clinical note was 7.71 ± 2.42. Using the information collected by a nurse using Ayu, a primary care physician could arrive at the correct diagnosis in 74% of cases, and correct triage decision in 88% of cases. Overall, we saw a high acceptability from nurses to use the system. Conclusions Ayu can capture an acceptable proportion of clinical information and can aid in collecting an evidence-based medical history by task-shifting some of the early investigational steps. Further development of Ayu to increase its information retrieval ability and ease of use by health workers is needed.

Initial Assessment of Trauma Patients

Introduction: The initial assessment of trauma patients is a critical and time-sensitive phase in the realm of emergency medicine. This presentation outlines the fundamental components and principles of conducting an effective initial assessment, which is essential for promptly identifying life-threatening injuries and ensuring timely interventions for patient stabilization.
 The primary objective of the initial assessment is to swiftly detect and address imminent life-threatening conditions. This process adheres to a structured approach, often following established protocols such as Advanced Trauma Life Support (ATLS).
 Commencing with the evaluation of the patient's airway, breathing, and circulation (ABCs), healthcare providers prioritize the maintenance of a patent airway, adequate respiration, and a stable circulatory system. Any life-threatening issues identified during this phase demand immediate intervention.
 Simultaneously, healthcare providers perform a concise yet comprehensive patient history and physical examination, gathering information about the injury's mechanism, the patient's medical background, and any pertinent details. This collected data serves as the foundation for subsequent assessments and treatment plans.
 The secondary survey, a more detailed and systematic examination, follows the initial assessment. This phase involves a thorough head-to-toe evaluation aimed at detecting injuries that may have been initially overlooked. Diagnostic procedures, including imaging studies and laboratory tests, may be initiated during this phase to further assess and diagnose injuries.
 The initial assessment places specific emphasis on identifying and managing conditions with rapid and potentially lethal deterioration, such as tension pneumothorax, cardiac tamponade, and massive hemorrhage.
 Throughout the assessment process, effective communication among the trauma team members is paramount to ensure a coordinated and efficient response. This includes making triage decisions and facilitating swift patient transport to the most appropriate care facility, all of which contribute to optimal trauma patient management.
 In conclusion, the initial assessment in trauma patients is a dynamic and systematic process designed to swiftly identify and address life-threatening injuries. By recognizing these injuries promptly, initiating timely interventions, and gathering critical patient information, healthcare providers and emergency responders play a vital role in ensuring the best possible outcomes for trauma patients. Training in these procedures is essential to equip healthcare teams with the skills and knowledge needed for successful trauma patient management.

Constipation in Children: An Example of A Conflict Situation

Constipation is a prevalent issue in the pediatric population and is predominantly of functional origin. It often presents with symptoms such as abdominal pain, vomiting, and anorexia, making it a significant complaint among young patients. A comprehensive patient history and physical examination are typically sufficient for the diagnosis of functional constipation. Early intervention and patient and parent education are crucial for the success of treatment, which involves dietary adjustments, toilet training, and medical interventions. This review outlines an approach to managing constipation in children.

Does the severity of atopic dermatitis change with allergic sensitization? Is it real or a myth?

Atopic dermatitis (AD) is a chronic inflammatory skin disease that can occur at any age. This study aimed to evaluate the impact of food allergy on disease severity as well as clinical/laboratory findings in children with AD. Clinical and laboratory data of AD patients evaluated for food allergy between January 2021 and December 2022 were examined retrospectively. Of the 52 patients evaluated, 32 (61.5%) were males, with a median age of 6 months (2-118 months). Among them, 26 (50%) had food allergies (FA) and five (9.6%) had inhalant allergen sensitivity. No significant difference in AD severity was observed between patients with and without FA. However, the FA group showed higher serum lactate dehydrogenase (LDH) levels (343.3 ± 81.5 U/L vs 297.7 ± 77.4 U/L; P = 0.011) and lower red cell distribution width (RDW). Inhalant allergen sensitivity was associated with higher AD severity. While guidelines recommend investigating food allergies in moderate to severe AD, this study found no significant difference in the relationship between AD severity and the presence of FA. However, inhalant allergen sensitivity was linked to increased AD severity. Therefore, a comprehensive patient history should include an evaluation of food allergies in children with AD, regardless of disease severity. Elimination and provocation tests related to suspected food items should be performed, and allergenic foods should be removed from the diet if they are found to contribute to the allergy.

Complications of Transcatheter Arterial Chemoembolization for Hepatocellular Carcinoma: A Case Report of Bronchobiliary Fistula Development in a 68-Year-Old Man.

BACKGROUND Bronchobiliary fistulas (BBFs) are abnormal communications between the biliary tract and bronchial tree. Transcatheter arterial chemoembolization (TACE) is a widely employed treatment for advanced hepatocellular carcinoma (HCC). While TACE is generally considered safe, there have been reports of severe complications. This case report is about a 68-year-old man who developed a BBF 6 months after undergoing TACE for HCC. CASE REPORT A 68-year-old man was diagnosed with HCC and underwent TACE at a local medical department. Two months after TACE, he presented with a liver abscess, which was drained and catheterized. Subsequently, the patient was transferred to our hospital. Initial MRI revealed abscesses in the right hepatic lobe extending into the lung cavity. Intrahepatic catheter replacement was performed. Six months after TACE, the patient developed cough and yellow sputum. Subsequent MRI confirmed smaller lung and liver abscesses, along with a BBF. Endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous catheter replacement were conducted, closing the BBF with a covered stent. Despite drainage, antibiotics, and nutritional support, the patient's condition deteriorated. Transition to hospice care was initiated, and the patient died due to sepsis and multiple organ failure. CONCLUSIONS This case highlights the importance of obtaining a comprehensive patient history when a patient has bile in the sputum, and discusses the rare but previously reported BBF as a complication of TACE for HCC. The presence of bile collections in the lungs and liver can result in tissue necrosis, potentially leading to chronic infection, emphasizing the need for early diagnosis and management.

Hypersensitivity pneumonitis: Principles in diagnosis and management.

Hypersensitivity pneumonitis: Principles in diagnosis and management.

Evaluating a Prototype Clinical Decision Support Tool for Chronic Pain Treatment in Primary Care.

The Chronic Pain Treatment Tracker (Tx Tracker) is a prototype decision support tool to aid primary care clinicians when caring for patients with chronic noncancer pain. This study evaluated clinicians' perceived utility of Tx Tracker in meeting information needs and identifying treatment options, and preferences for visual design. We conducted 12 semi-structured interviews with primary care clinicians from four health systems in Indiana. The interviews were conducted in two waves, with prototype and interview guide revisions after the first six interviews. The interviews included exploration of Tx Tracker using a think-aloud approach and a clinical scenario. Clinicians were presented with a patient scenario and asked to use Tx Tracker to make a treatment recommendation. Last, participants answered several evaluation questions. Detailed field notes were collected, coded, and thematically analyzed by four analysts. We identified several themes: the need for clinicians to be presented with a comprehensive patient history, the usefulness of Tx Tracker in patient discussions about treatment planning, potential usefulness of Tx Tracker for patients with high uncertainty or risk, potential usefulness of Tx Tracker in aggregating scattered information, variability in expectations about workflows, skepticism about underlying electronic health record data quality, interest in using Tx Tracker to annotate or update information, interest in using Tx Tracker to translate information to clinical action, desire for interface with visual cues for risks, warnings, or treatment options, and desire for interactive functionality. Tools like Tx Tracker, by aggregating key information about past, current, and potential future treatments, may help clinicians collaborate with their patients in choosing the best pain treatments. Still, the use and usefulness of Tx Tracker likely relies on continued improvement of its functionality, accurate and complete underlying data, and tailored integration with varying workflows, care team roles, and user preferences.

Management of Partial Tears of the Anterior Cruciate Ligament: A Review of the Anatomy, Diagnosis, and Treatment.

Partial anterior cruciate ligament (ACL) tears comprise an estimated 10% to 27% of isolated ACL injuries. Partial ACL tears may be challenging to clinically diagnose. We reviewed relevant studies focusing on the anatomy, diagnosis, imaging, and treatment of a partial injury with the goal of providing guidance to clinicians. Although a comprehensive patient history, thorough clinical examination, and imaging studies are helpful in arriving at a diagnosis, the benchmark for diagnosis remains visualization and examination of the ACL at the time of knee arthroscopy. Currently, limited data exist about the long-term outcomes of nonsurgical treatment. Some studies demonstrate that younger, active patients have the risk of progressing to a complete ACL rupture with conservative treatment. The decision to proceed with surgery is based on careful history and physical examination findings that suggest either a "functional" or "nonfunctional" ACL. Surgical treatment consists of augmenting the intact bundle with a selective bundle reconstruction versus a traditional ACL reconstruction. Selective bundle reconstruction has limited data available but is an option. The best evidence supports traditional ACL reconstruction for the surgical management of patients with documented nonfunctional partial tears of the ACL.

Radiologic Differentiation of Adrenal Lesions and Its Impact on Patient Management

Adrenal lesions are a relatively common incidental finding and are estimated to be present in 4.4% of all abdominal CT scans.1 The detection of an adrenal lesion often necessitates a thorough clinical evaluation that frequently requires a comprehensive patient history, biochemical studies, and radiologic studies such as dedicated adrenal protocol CT or MRI. The primary goal of additional radiologic studies is to differentiate benign from malignant adrenal lesions. It is, therefore, important for the radiologist to be familiar with a variety of benign and malignant adrenal lesions and to recognize distinctive imaging characteristics that can help make this distinction. This article reviews typical and useful imaging features of more commonly encountered benign and malignant adrenal lesions.

Cancer Patients: Relevant Aspects for Anesthesiology

Surgical oncology makes up an essential part of all surgical procedures performed. Anesthetists can contribute significantly to the treatment success by a thorough pre-operative assessment of patients. Cancer patients are not only in general at higher risk for thrombosis and anemia but can also suffer from a plethora of adverse effects from modern cancer drugs. Hence, it is the responsibility of anesthetists to gather knowledge about the changes in organ systems due to the rapidly increasing list of anti-cancer agents. This article serves as a review from anesthetists to anesthetists conveying the important aspects for taking a comprehensive patient history as well as summarizing the adverse events of major drug classes currently in use in oncology.

Preoperative laboratory testing: Implications of "Choosing Wisely" guidelines.

Preoperative laboratory testing is often necessary and can be invaluable for diagnosis, assessment, and treatment. However, performing routine laboratory tests for patients who are considered otherwise healthy is not usually beneficial and is costly. It is estimated that $18 billion (U.S.) is spent annually on preoperative testing, although how much is wasteful remains unknown. Ideally, a targeted and comprehensive patient history and physical exam should largely determine whether preprocedure laboratory studies should be obtained. Healthcare providers, primarily anesthesiologists, should remain cost-conscious when ordering specific laboratory or imaging tests prior to surgery based on available literature. We review the overall evidence and key points from the Choosing Wisely guidelines, the identification of potential wasteful practices, possible harms of testing, and key clinical findings associated with preoperative laboratory testing.

Feasibility analysis of conducting observational studies with the electronic health record

BackgroundThe secondary use of electronic health records (EHRs) promises to facilitate medical research. We reviewed general data requirements in observational studies and analyzed the feasibility of conducting observational studies with structured EHR data, in particular diagnosis and procedure codes.MethodsAfter reviewing published observational studies from the University Hospital of Erlangen for general data requirements, we identified three different study populations for the feasibility analysis with eligibility criteria from three exemplary observational studies. For each study population, we evaluated the availability of relevant patient characteristics in our EHR, including outcome and exposure variables. To assess data quality, we computed distributions of relevant patient characteristics from the available structured EHR data and compared them to those of the original studies. We implemented computed phenotypes for patient characteristics where necessary. In random samples, we evaluated how well structured patient characteristics agreed with a gold standard from manually interpreted free texts. We categorized our findings using the four data quality dimensions “completeness”, “correctness”, “currency” and “granularity”.ResultsReviewing general data requirements, we found that some investigators supplement routine data with questionnaires, interviews and follow-up examinations. We included 847 subjects in the feasibility analysis (Study 1 n = 411, Study 2 n = 423, Study 3 n = 13). All eligibility criteria from two studies were available in structured data, while one study required computed phenotypes in eligibility criteria. In one study, we found that all necessary patient characteristics were documented at least once in either structured or unstructured data. In another study, all exposure and outcome variables were available in structured data, while in the other one unstructured data had to be consulted. The comparison of patient characteristics distributions, as computed from structured data, with those from the original study yielded similar distributions as well as indications of underreporting. We observed violations in all four data quality dimensions.ConclusionsWhile we found relevant patient characteristics available in structured EHR data, data quality problems may entail that it remains a case-by-case decision whether diagnosis and procedure codes are sufficient to underpin observational studies. Free-text data or subsequently supplementary study data may be important to complement a comprehensive patient history.

Identifying and differentiating stroke and stroke mimics.

Stroke mimics are common differential diagnoses of stroke. This article describes common stroke mimics and their presentations. It provides nurses with an overview of how to distinguish stroke mimics from a stroke, and practical information on triaging and diagnosing stroke and stroke mimics in the clinical setting. Stroke and stroke mimics have several similarities and several important differences. A comprehensive patient history, clinical examination, use of assessment tools and the results of medical imaging can guide nurses to differentiate stroke from a stroke mimic.

Persistent Buccal Swelling: Diagnostic Dilemma

Taking a systematic and comprehensive patient history is undoubtedly an essential tool for a proper diagnosis. We report a unique case of a patient presenting with persistent buccal swelling, a rare presentation of two unrelated pathologies occurring concurrently. In this case, the presence of a lipoma was concealed by a dental abscess and an incomplete patient history.