ID teaching notes History taking in Infectious Diseases Diseases (introductory lecture) This is similar to any other speciality, but certain areas are of particular importance, especially seeking risk factors for infection. Presenting complaints A reminder of some general points: Initially allow the patients to tell their own story Ask for clarification if need be by asking simple questions. Avoid leading questions Each major symptom needs to be analysed in detail e.g. Diarrhoea: severity, duration, frequency, consistency, colour / presence of blood, associated features e.g. Fever: duration, frequency, temperature recordings, night sweats, rigors, associated features If the patient provides a diagnosis for their symptoms, e.g. 'flu, ask for f or clarification as this might include a variety of different symptoms Clarify the timing of any exposure to start of symptoms - this gives possible timing of incubation which may include or exclude certain infections (e.g. return from travel 6 weeks before symptoms would exclude short incubation infections such as dengue fever - 4 days)
Past Medical History Ask about previous infections frequent severe infections might suggest underlying immunosuppression immunosuppression some infections might produce lifelong lifelong immunity e.g. measles, others a risk of reactivation e.g. herpes viruses sexually transmitted infections healthcare associated infections e.g. MRSA, C difficile • •
• •
Systematic enquiry Ask about specific symptoms for each body system - don't forget skin & ENT Ask about symptoms of fever - rigors, night sweats Remember to check whether female patients could be pregnant some infections may cause more severe illness in pregnancy e.g. hepatitis E, chickenpox some infections may cause danger to the fetus e.g. rubella antimicrobial antimicro bial therapy may have to be adjusted •
• •
Family History Are there relatives with a history of an infection which the patient might have caught? (e.g.TB) Are there relatives with a history of frequent severe infections suggesting an inherited immunodeficiency? Drugs Remember: Immunosuppression Immunosuppression - e.g. steroids, methotrexate, cyclosporin Antibiotics given recently - may show that current current infection infection is is due to resistant resistant organisms, or increased risk of C difficile Antacid drugs - reduce stomach acid so that ingested bugs are more likely to survive Malarial prophylaxis for travel, travel, including checking for adherence adherence • •
•
•
1
ID teaching - Introductory lecture – Infectious Diseases History
Vaccinations Up-to-date? Up-to-dat e? May have missed primary course Evidence of response – e.g. hepatitis B vaccine vaccine response response may be tested by checking checking for antibodies in healthcare workers Prior to travel • •
•
Allergies (especially medication) Antibiotic allergies: Ask what what actually happened when the patient took the drug in question. A mild reaction may not preclude giving the same class of antibiotics if the illness is severe Vomiting, or or other adverse effects, after after an antibiotic sometimes gets labelled labelled as as an allergy - you might still want to avoid this antibiotic but others in the same class could be tried. •
•
Risk factors for infection (examples of infections in brackets) Contacts family, friends, workmates who might have infection recent stay in a healthcare institution - may have been been in contact with with healthcare healthcare associated pathogens (e.g. MRSA, C difficile) • •
Recent hospital procedure surgical site infection infections from invasive devices e.g. urinary urinary catheter, iv lines • •
Occupation Food handlers i.e. handling raw food- also important because of Public Health Health risk of them spreading infection to others (salmonella, (salmonella, campylobacter) campylobacter) Animal exposure - farmers, vets etc (leptospirosis, cryptosporidiosis) cryptosporidiosis) Sewage workers (leptospirosis, (leptospirosis, hepatitis A) Healthcare workers (viral gastroenteritis, blood-borne viruses, TB) •
• • •
Travel • •
•
•
When and where they went & when they got back? What they did? Sexual contacts (HIV, Hepatitis B, STDs) o Food & drink (GI infections, enteric fever, hepatitis A or E) o Accommodation Accommodat ion including air conditioning (Legionnaire's) o Swimming in unchlorinated unchlorinate d water (schistosomiasis, (schistosomiasis, GI infections) o What precautions they took? Vaccinations o Malaria prophylaxis prophylaxis and adherence to this o Mosquito nets / insect repellent o Were they or any one else ill
Leisure activities hiking (tick bites - Lyme disease) canoeing & fishing (leptospirosis) • •
Food history food not properly cooked or stored (GI infections) meals out including takeaways (GI infections) shellfish (hepatitis A) poultry (campylobacter, (campylobacter, salmonella) salmonella) • • • •
2
ID teaching - Introductory lecture – Infectious Diseases History
•
raw or undercooked undercooked eggs (salmonella)
Exposure to animals & birds pets - their own and other people's (psittacosis, campylobacter) campylobacter) farm visits (psittacosis, campylobacter, cryptosporidiosis) cryptosporidiosis) • •
Risk factors for blood borne viruses (HIV, Hepatitis B or C) injecting drug use - IDU transfusion of blood blood p products roducts especially especially before screening for HIV/Hep HIV/Hep C started (1980s) or overseas amateur tattoos & body-piercing body-piercing • •
•
Sexual history (HIV, Hepatitis B, STDs) unprotected sex new partners partners with high risk behaviour behaviour e.g. IDU men who have sex with men • • • •
September 2012
3
