Editors: Thomas, James; Monaghan, Tanya Title: Oxford Handbook of Clinical Examination and Practical kills, !

st Edition Co"yright #$%&&' Oxford (ni)ersity Press * Table of Contents * Cha"ter % + The History Cha"ter % The History P,-. History+taking The history is a "atient/s acco0nt of their illness together 1ith other rele)ant information that yo0 ha)e gleaned from them, 2ike all things in medicine, there is a tried and tested standard se30ence 1hich yo0 sho0ld stick to and is 0sed by all "ractitioners, 4t is good "ractice to make 30ick notes 1hilst talking to the "atient that yo0 can 0se to 1rite a thoro0gh history after1ards567don/t doc0ment e)ery 1ord they say as this breaks yo0r interaction8 9y the end of the history taking, yo0 sho0ld ha)e a good idea as to a diagnosis or ha)e se)eral differential diagnoses in mind, The examination is yo0r chance to confirm or ref0te these by gaining more information, History+taking is not a "assi)e "rocess, :o0 need to kee" yo0r 1its abo0t yo0 and gently g0ide the "atient into gi)ing yo0 rele)ant information 0sing all the comm0nication skills described in Cha"ter !, :o0 sho0ld break the history do1n 0nder the follo1ing headings and record it in the notes in this order567many "eo"le "refer to 0se the standard abbre)iations ;sho1n in 9ox %,!< instead of 1riting o0t the heading in f0ll56= 9ox %,! The standard history frame1ork Presenting com"laint ;PC< History of "resenting com"laint ;HPC<

ystematic en30iry ; E< Past medical history ;PMH< >llergies ?r0g history ;?Hx< >lcohol moking @amily history ;@Hx< ocial history ; Hx<

The o0tline abo)e is the a0thors/ fa)o0red method567slight )ariations exist,

5AB Many "eo"le 1ill "0t 56Csmoking56D and 56Calcohol56D as "art of the 56Csocial history56D, Ee feel that as these can ha)e s0ch an im"ortant im"act on health they deser)e their o1n s"ot and are more than sim"ly 56C1hat the "atient does in their s"are time56D, 4t is good "ractice in medicine to 1atch 1hat other "ractitioners do and ada"t the "arts that yo0 feel are done 1ell to yo0r o1n style, making them "art of yo0r o1n ro0tine, P,-' (sing this book This book is di)ided into cha"ters by organ system, 4n each cha"ter, there are s0ggestions as to ho1 to "roceed de"ending on the nat0re of the "resenting com"laint and notes on 1hat yo0 sho0ld es"ecially ask abo0t 0nder each of the abo)e headings, These are not exha0sti)e and are intended as g0idance to s0""lement a thoro0gh history, 9ox %,% Fecording the history ?oc0mentation is a )ital "art of all medical interactions, The history sho0ld be recorded in the "atient/s notes according to the standard frame1ork o""osite 0sing the r0les and "roced0res described 0nder 56C1ritten comm0nication56D in Cha"ter ! ; ",-&<, Ee direct readers there no1, Femember, if it isn/t 1ritten do1n, it didn/t ha""en8 9ox %,- Collateral histories There are many sit0ations 1hen the "atient may be 0nable to gi)e a history ;e,g, they are 0nconscio0s, delirio0s, demented, dys"hasic etc,<, 4n these sit0ations, yo0 sho0ld make an effort to s"eak to all those 1ho can hel" yo0 fill in the ga"s567not only regarding 1hat ha""ened to bring the "atient to yo0r attention no1, b0t also regarding their 0s0al medication, f0nctional state, li)ing arrangements, and so on, Ehen taking a history from a so0rce other than the "atient, be s0re to doc0ment clearly that this is the case and 1hy the "atient is 0nable to s"eak for themsel)es, (sef0l so0rces of information incl0de: Felati)esGcohabitants, Close friendsGroom+mates,

The HP or other members of the "rimary care team, The "harmacist, The 1arden ;if in sheltered accommodation<, The staff at the n0rsing or residential home, >nyone 1ho 1itnessed the e)ent,

P,-I Presenting com"laint ;PC< This is the "atient/s chief sym"tom;s< in their o1n 1ords and sho0ld be no more than a single sentence,

4f the "atient has se)eral sym"toms, "resent them as a list 1hich yo0 can ex"and on later in the history, >sk the "atient an o"en 30estion s0ch as 56CEhat/s the "roblemJ56D or 56CEhat made yo0 come to the doctorJ56D, Each "ractitioner 1ill ha)e their o1n style, :o0 sho0ld choose a "hrase that s0its yo0 and yo0r manner ;one of the a0thors fa)o0rs 56Ctell me the story56D after a brief introd0ction<,

The 30estion 56C1hat bro0ght yo0 hereJ56D 0s0ally brings the res"onse 56Can amb0lance56D or 56Cthe taxi56D567each "atient 0nder the im"ression that they are the first to crack this sho1+sto""er of a Koke, This is, therefore, best a)oided, 5AB Femember, this is the "roblem in the "atient/s 1ords, 56CHaemo"tysis56D is rarely a "resenting com"laint b0t 56Cco0ghing 0" blood56D may 1ell be8 History of the "resenting com"laint ;HPC< Here, yo0 ask abo0t and doc0ment the details of the "resenting com"laint, 9y the end of this, yo0 sho0ld ha)e a clear idea abo0t the nat0re of the "roblem along 1ith exactly ho1 and 1hen it started, ho1 the "roblem has "rogressed o)er time, and 1hat im"act it has had on the "atient in terms of their general "hysical health, "sychology, social, and 1orking li)es, This is best tackled in % "hases: @irst, ask an o"en 30estion ;as abo)e< and allo1 the "atient to talk thro0gh 1hat has ha""ened for abo0t % min0tes, ?on/t interr0"t8 Enco0rage the "atient 1ith non+)erbal res"onses and make discreet notes, This also allo1s yo0 to make an initial assessment of the "atient in terms of ed0cation le)el, "ersonality, and anxiety, (sing this information, yo0 can adK0st yo0r res"onses and interaction, 4t sho0ld also become clear to yo0 exactly 1hat sym"tom the "atient is most concerned abo0t, 4n the second "hase, yo0 sho0ld re)isit the 1hole story asking more detailed 30estions, 4t may be 0sef0l to say 56C4/d K0st like to go thro0gh the story again, clarifying some details56D, This is yo0r chance to )erify time+lines and the relationshi" of one sym"tom to another, :o0 sho0ld also be caref0l to clarify "se0do+medical terms ;exactly 1hat does the "atient mean by 56C)ertigo56D, 56Cfl056D or 56Crhe0matism56DJ<, Femember, this sho0ld feel like a con)ersation, not an interrogation8 5AB The standard feat0res that sho0ld be determined for any sym"tom are sho1n o""osite, along 1ith the additional feat0res regarding 56C"ain56D, 5AB ee the rest of this book for g0idance on tackling other "resenting com"laints, >t the end of the history of "resenting com"laint, yo0 sho0ld ha)e established a "roblem list :o0 sho0ld r0n thro0gh these 1ith the "atient, s0mmarising 1hat yo0 ha)e been told and ask them if yo0 ha)e the information correct and if there are is anything f0rther that they 1o0ld like to share 1ith yo0, P,-L 9ox %,M @or each sym"tom, determine: The exact nat0re of the sym"tom, The onset:
o

The date it began,

o o

Ho1 it began ;e,g, s0ddenly, grad0ally567o)er ho1 longJ< 4f longstanding, 1hy is the "atient seeking hel" no1J

Periodicity and fre30ency:

o o o

4s the sym"tom constant or intermittentJ Ho1 long does it last each timeJ Ehat is the exact manner in 1hich it comes and goesJ

Change o)er time:

o

4s it im"ro)ing or deterioratingJ

Exacerbating factors:
o

Ehat makes the sym"tom 1orseJ

Felie)ing factors:
o

Ehat makes the sym"tom betterJ

>ssociated sym"toms,

9ox %,N @or "ain, determine: ite ;1here is the "ain 1orst567ask the "atient to "oint to the site 1ith one finger<, Fadiation ;does the "ain mo)e any1here elseJ<,

Character ;i,e, 56Cd0ll56D, 56Caching56D, 56Cstabbing56D, 56Cb0rning56D etc,<, e)erity ;scored o0t of !&, 1ith 56C!&56D as the 1orst "ain imaginable<, Mode and rate of onset ;ho1 did it come on567o)er ho1 longJ<, ?0ration, @re30ency, Exacerbating factors, Felie)ing factors, >ssociated sym"toms ;e,g, na0sea, dys"e"sia, shortness of breath<,

9ox %,. 2ong+standing "roblems 4f the sym"tom is long+standing, ask 1hy the "atient is seeking hel" no1, Has anything changedJ 4t is often 0sef0l to ask 1hen the "atient 1as last 1ell, This hel"s foc0s their minds on the start of the "roblem 1hich may seem distant and less im"ortant to them, P,M&

ystematic en30iry ; E< >fter talking abo0t the "resenting com"laint, yo0 sho0ld "erform a brief screen of the other bodily systems, This often "ro)es to be more im"ortant than yo0 ex"ect, finding sym"toms that the "atient had forgotten abo0t or identifying secondary, 0nrelated, "roblems that can be addressed, The 30estions asked 1ill de"end on the disc0ssion that has gone before, 4f yo0 ha)e disc0ssed chest "ain in the history of "resenting com"laint, there is no need to ask abo0t it again8 >sk the "atient if they ha)e any of the follo1ing sym"toms 56= Heneral sym"toms Eeight change ;loss or gain<, change in a""etite ;loss or gain<, fe)er, lethargy, malaise, Fes"iratory sym"toms Co0gh, s"0t0m, haemo"tysis, shortness of breath, 1heeOe, chest "ain, Cardio)asc0lar sym"toms hortness of breath on exertion, "aroxysmal noct0rnal dys"noea, chest "ain, "al"itations, ankle s1elling, ortho"noea, cla0dication, Hastrointestinal sym"toms 4ndigestion, abdominal "ain, na0sea, )omiting, a change in bo1el habit, consti"ation, diarrhoea, PF blood+loss, dys"hagia, Henito+0rinary sym"toms (rinary fre30ency, "oly0ria, dys0ria, haemat0ria, noct0ria, menstr0al "roblems, im"otence, Pe0rological sym"toms Headaches, diOOiness, tingling, 1eakness, tremor, fits, faints, 56Cf0nny t0rns56D, black+o0ts, s"hincter dist0rbance, 2ocomotor sym"toms >ches, "ains, stiffness, s1elling, kin sym"toms 20m"s, b0m"s, 0lcers, rashes, itch, P,M! P,M% Past medical history ;PMH< ome as"ects of the "atient/s "ast illnesses or diagnoses may ha)e already been co)ered, Here, yo0 sho0ld obtain detailed information abo0t "ast illness and s0rgical "roced0res, >sk if they/re 56C0nder the doctor for anything else56D or ha)e e)er been to hos"ital before, Ens0re yo0 get dates and location for each e)ent, There are some conditions 1hich yo0 sho0ld s"ecifically ask "atients abo0t and these are sho1n belo1, @or each condition, ask: Ehen 1as it diagnosedJ Ho1 1as it diagnosedJ

Ho1 has it been treatedJ

@or o"erations, ask abo0t any "re)io0s anaesthetic "roblems, >sk also abo0t imm0niOations and com"anyGins0rance medicals, 9ox %,' Past medical history567ask s"ecifically abo0t: ?iabetes, Fhe0matic fe)er,

Ja0ndice, Hy"ercholesterolaemia, Hy"ertension, >ngina, Myocardial infarction, troke or T4>, >sthma, T9, E"ile"sy, >naesthetic "roblems, 9lood transf0sions,

9ox %,I ?on/t take anything for granted8 @or each condition that the "atient re"orts ha)ing, ask exactly ho1 it 1as diagnosed ;1hereJ by 1homJ< and ho1 it has been treated since, @or exam"le, if the "atient re"orts 56Casthma56D, ask 1ho made the diagnosis, 1hen the diagnosis 1as made, if they ha)e e)er had l0ng f0nction tests, if they ha)e e)er seen a chest "hysician at a hos"ital, if they are taking any inhalersJ Occasionally, "atients 1ill gi)e a long+ standing sym"tom a medical name 1hich can be )ery conf0sing, 4n this exam"le, the "atient/s 56Casthma56D co0ld be ho1 they refer to their 1heeOe 1hich is, in fact, d0e to congesti)e cardiac fail0re, P,MP,MM >llergies This sho0ld be doc0mented se"arately from the 56Cdr0g history56D ;belo1< d0e to its im"ortance, >sk if the "atient has any allergies or 56Cis allergic to anything56D if they are 0nfamiliar 1ith the term, 9e s0re to "robe caref0lly as "eo"le 1ill often tell yo0 abo0t their hay+fe)er and forget

abo0t the rash they had 1hen they took "enicillin, >sk s"ecifically if they ha)e had any 56Creactions56D to dr0gs or medication, 5AB 4f an allergy is re"orted, yo0 sho0ld obtain the exact nat0re of the e)ent and decide if the "atient is describing a tr0e allergy, an intolerance, or sim"ly an 0n"leasant side+effect, ?r0g history ;?Hx< Here, yo0 sho0ld list all the medication the "atient is taking, incl0ding the dose and fre30ency of each "rescri"tion, 4f the "atient is 0ns0re, yo0 sho0ld confirm 1ith the HP or "harmacy, :o0 sho0ld make a s"ecial note of any dr0gs that ha)e been started or sto""ed recently, :o0 sho0ld also ask abo0t com"liance567does the "atient kno1 1hat dose they takeJ ?o they e)er miss dosesJ 4f they are not taking the medication5671hat/s the reasonJ ?o they ha)e any com"liance aids s0ch as a "re+"ackaged 1eekly s0""lyJ The "atient may not consider some medications to be 56Cdr0gs56D so s"ecific 30estioning is re30ired, ?on/t forget to ask abo0t: Eye+dro"s, 4nhalers,

lee"ing "ills, Oral contrace"tion, O)er the co0nter dr0gs ;bo0ght at a "harmacy<, )itamin s0""lements, Herbal remedies, 56C4llicit56D or 56Crecreational56D dr0g+0se,

>lcohol :o0 sho0ld attem"t to 30antify, as acc0rately as yo0 can, the amo0nt of alcohol cons0med "er 1eek567and also establish if the cons0m"tion is s"read e)enly o)er the 1eek or concentrated into a smaller "eriod, 4n the (Q, alcohol is 30antified in 56C0nits56D, One 0nit is !&ml of "0re alcohol, The 0nit+ content of some common drinks is sho1n o""osite, 4n many E0ro"ean co0ntries, and the ( , alcohol is 30antified as 56Cstandard drinks56D, 4n the ( , a 56Cstandard drink56D contains &,NM o0nces of alcohol 1hich is abo0t !,N (Q 56C0nits56D, P,MN 9ox %,L Fecommended 1eekly alcohol cons0m"tion >t the time of 1riting, the (Q go)ernment recommends a maxim0m of %! 0nitsG1eek for men and !M 0nitsG1eek for 1omen, 9ox %,!& (nits of alcohol in common drinks ! "int ordinary strength lager R % 0nits ! "int strong lager R - 0nits

! "int bitter R % 0nits ! "int ordinary strength cider R % 0nits

! !'Nml glass of red or 1hite 1ine 5ST % 0nits ! "0b meas0re of s"irits R ! 0nit ! alco"o" R !,N 0nits

o0rce: ?e"artment of Health, (Q ;111,dh,go),0k< P,M. moking >ttem"t to 30antify the habit in 56C"ack+years56D, ! "ack+year is %& cigarettes "er day for one year, ;e,g, M&Gday for ! year R % "ack+years; !&Gday for % years R ! "ack+year<, >sk abo0t "re)io0s smoking as many 1ill call themsel)es non+smokers if they ga)e 0" yesterday or e)en on their 1ay to the hos"ital or clinic8

Femember to ask abo0t "assi)e smoking,

9e a1are of c0lt0ral iss0es567smoking is forbidden for ikhs, for exam"le, and they may take offence at the s0ggestion8 9e1are of a""earing K0dgemental, P,M' 9ox %,!! Haggling and the art of 30antification moking and alcohol histories are notorio0sly 0nreliable567alcohol es"ecially so, The "atient may be trying to "lease yo0 or feel embarrassed abo0t o"enly admitting their tr0e cons0m"tion, Haining an acc0rate acco0nt of cons0m"tion can sometimes feel like haggling, There are t1o ste"s in this "rocess, @irstly, a""ear non+K0dgmental and resist acting s0r"rised in any 1ay, e)en in the face of li30or+ or tobacco+cons0m"tion that yo0 may consider excessi)e and 0n1ise, econdly, if the "atient remains reticent ;56C4 smoke a fe156D<, s0ggest a n0mber567b0t start )ery high ;56Cshall 1e say .& a dayJ56D< and the "atient 1ill 0s0ally gi)e yo0 a n0mber nearer the tr0e amo0nt ;56Coh no, more like %&56D<, 4f yo0 1ere to start lo1, the same "atient may only admit to half that, P,MI @amily history ;@Hx< The @Hx details: The make 0" of the c0rrent family, incl0ding the age and gender of "arents, siblings, children, and extended family as rele)ant, The health of the family,

:o0 sho0ld ask abo0t any diagnosed conditions in other li)ing family members, :o0 sho0ld also doc0ment the age of death and ca0se of death for all deceased first degree relati)es and other family members if yo0 feel it is a""ro"riate, 4t may hel" to dra1 a family+tree as sho1n o""osite, These are "artic0larly 0sef0l in "aediatric assessments, ocial history ; Hx< This is yo0r chance to doc0ment the details of the "atient/s "ersonal life 1hich are rele)ant to the 1orking diagnosis, the "atient/s general 1ell+being and reco)eryGcon)alescence, 4t 1ill hel" to 0nderstand the im"act of the illness on the "atient/s f0nctional stat0s, This is a )ital "art of the history b0t sadly, "erha"s beca0se it comes at the end, it is often gi)en only brief attention, The disease, and indeed the "atient, do not exist in a )ac00m b0t are "art of a comm0nity 1hich they interact 1ith and contrib0te to, Eitho0t these details, it is im"ossible to take an holistic a""roach to the "atient/s 1ellbeing, Establish: Marital stat0s, ex0al orientation,

Occ0"ation ;or "re)io0s occ0"ations if retired<,

o

:o0 sho0ld establish the exact nat0re of the Kob if it is 0nclear567does it in)ol)e sitting at a desk, carrying hea)y loads, tra)ellingJ

Other "eo"le 1ho li)e at the same address, The ty"e of accommodation ;e,g, ho0se, flat567and on 1hat floor<, ?oes the "atient o1n their accommodation or rent itJ >re there any stairsJ Ho1 manyJ ?oes the "atient ha)e any aids or ada"tations in their ho0seJ ;e,g, rails near the bath, stairlift etc<, ?oes the "atient 0se any 1alking aids ;e,g, stick, frame scooter<J ?oes the "atient recei)e any hel" day+to+dayJ
o o

Eho fromJ ;e,g, family, friends, social ser)ices,< Eho does the la0ndry, cleaning, cooking, and sho""ingJ

?oes the "atient ha)e relati)es li)ing nearbyJ Ehat hobbies does the "atient ha)eJ ?oes the "atient o1n any "etsJ Has the "atient been abroad recently or s"ent any time abroad in the "astJ ?oes the "atient dri)eJ

P,ML 9ox %,!% @amily trees Con)entionally, males are re"resented by a s30are ;5AU< and females by a circle ;5VW<, The "atient that yo0 are talking to is called the "ro"osit0s and is indicated by a small arro1 ; <, HoriOontal lines re"resent marriages or relationshi"s res0lting in a child, Xertical lines descend from these, connecting to a horiOontal line from 1hich the children 56Chang56D, :o0 can add ages and ca0ses of death, @amily members 1ho ha)e died are re"resented by a diagonal line thro0gh their circle or s30are ; , < and those 1ith the condition of interest are re"resented by shaded sha"es ; ,

<, Exam"le ! O0r "atient is an only child and has no children, his "arents are ali)e b0t all his grand"arents ha)e died of different ca0ses, Exam"le % O0r "atient s0ffers from colon cancer and has no children, he has a brother 1ho is 1ell, Her "arents are both ali)e and her mother also has colon cancer, Of her grand"arents, only her "aternal grandfather is ali)e, Her maternal grandfather died of colon cancer, Exam"le - O0r "atient has e"ile"sy, as does her father, he has - children, % boys and a girl, One of the boys also has e"ile"sy, P,N& The elderly "atient Obtaining a history from older "eo"le might be regarded as no greater task than from any "atient567ho1e)er cogniti)e decline, deafness, and ac0te illness can make this diffic0lt, Hetting to gri"s 1ith taking a good history from older "eo"le is a skill yo0 1ill find 0sef0l in all other sit0ations, Ehilst the history is key for making diagnoses, it is an o""ort0nity for so m0ch more567yo0r first interaction 1ith an ;older< "atient sets im"ortant first im"ressions, > skilf0l history not only rea"s diagnostic re1ards, b0t marks yo0 as a com"etent doctor 1ho can gain tr0st, reass0re, and comm0nicate 1ell 1ith "atients in any challenging sit0ation, Qey "oints 56C2earn to listen56D: it can be tem"ting to ask lots of 30estions to obtain e)ery fact in the history, "artic0larly if yo0 are r0shed, ?oing this 1ill not only fr0strate and offend yo0r "atient ;beca0se yo0 clearly don/t listen<, b0t 1ill also risk yo0 missing im"ortant facts, 4nstead, learn to stay 30iet567and listen in detail to the history of the "resenting com"laint 1hich may only be -+M min0tes, b0t gi)es yo0r "atient a chance to be heard; seemingly irrele)ant detail is often 0sef0l 1hen "atients ha)e the chance to "0t it in

context, 4t often sa)es yo0 time, as other key information may emerge straight a1ay, and yo0 can better foc0s the history, Problem lists: "atients 1ith chronic illness or m0lti"le diagnoses may ha)e more than one strand to their ac0te "resentation, Consider breaking the history of the "resenting com"laint do1n into a "roblem list e,g, ;!< 1orsening heart fail0re; ;%< continence "roblems; ;-< diarrhoea; ;M< falls, This can often re)eal key interactions bet1een diagnoses yo0 might not ha)e tho0ght abo0t, ?r0g history: remember "oly"harmacy and that "atients may not remember all the treatments they take, 9e a1are that more dr0gs mean more side effects and less concordance567so ask 1hich are taken and 1hy567;older< "eo"le are often 30ite honest abo0t 1hy they omit tablets, Eye dro"s, slee"ing "ills, and laxati)es are often regarded as non+medicines by "atients, so be thoro0gh and ask se"arately567and a)oid "reci"itating deliri0m d0e to ac0te 1ithdra1al of benOodiaOe"ines, @0nctional history: a com"rehensi)e f0nctional history is a cornerstone of yo0r history taking in older "eo"le5671e make no a"ologies for reminding yo0 abo0t this thro0gho0t this book, ?iseases may not c0red or modified, b0t their key com"onent567the effects on "atients and their li)es might be easily transformed thro0gh mani"0lation of acti)ities of daily li)ing, Femember to ask abo0t formal and informal s0""ort for the "atient at home567ha)e things res0lted in a crisis for the "atient beca0se a caring neighbo0r or friend is 0n1ellJ 9e "olite567and ask tactf0lly abo0t benefits, incl0ding >ttendance >llo1ance567many "atients do not realise they might be eligible, so co0ch yo0r 30estions 1ith an ex"lanation that ad)ice might be a)ailable too, P,N!

ocial history: is exactly that, and sho0ld com"lement the f0nctional history, Occ0"ation ;other than 56Cretired56D< can be of )al0e 1hen faced 1ith a ne1 diagnosis of "0lmonary fibrosis or bladder cancer and may gi)e yo0r "atient a chance to sketch o0t more abo0t their li)es, En30ire abo0t family567don/t ass0me that a relati)e may be able to 0ndertake more hel", as they may li)e far a1ay; the "atient may still ha)e a s"o0se567b0t be se"arated, Chat 1ith "atients abo0t their daily li)es5670nderstanding interests and "0rs0its can hel" distract an 0n1ell "atient, gi)e ho"e for the f0t0re, and act as a s"0r for reco)ery and meaningf0l rehabilitation,

9ox %,!- > note on narrati)es >kin to 56Clearning to listen56D is a recognition that many "atients might not deli)er their histories in a style that fits the traditional "attern described in this cha"ter, P0shing ;older< "atients thro0gh histories is not to be recommended, as indicated abo)e, Elders 1ill often disc0ss e)ents and "references 1ith a constit0ted story, and it is im"ortant to recogniOe the )al0e of this, Parrati)e analysis at its most sim"le567i,e, yo0r ability to listen and inter"ret567is a )ital skill for all clinicians, 2istening to stories allo1s yo0 to 0nderstand "atients/ "references, ho"es and fears,

Femember also that older "atients often ha)e different )ie1s abo0t 1hat they 1ant from their doctors, Their 56Cagendas56D may differ h0gely from 1hat yo0 think treatment "lans sho0ld be, b0t they may not make their )ie1s kno1n thro0gh fear of offending yo0, 4f yo0 are 0ns0re, al1ays ask567learning to in)ol)e yo0r "atients in key decisions abo0t their care 1ill make yo0 a better clinician,

Ee thank ?r Fichard @0ller for "ro)iding this "age,