History of Present Illness (HPI) Obtaining an accurate history is the critical first step in determining the etio logy

of a patient's problem. A large percentage of the time, you will actually b e able make a diagnosis based on the history alone. The value of the history, of course, will depend on your ability to elicit relevant information. Your sense of what constitutes important data will grow exponentially in the coming years a s you gain a greater understanding of the pathophysiology of disease through inc reased exposure to patients and illness. However, you are already in possession of the tools that will enable you to obtain a good history. That is, an ability to listen and ask common-sense questions that help define the nature of a partic ular problem. It does not take a vast, sophisticated fund of knowledge to succes sfully interview a patient. In fact seasoned physicians often lose site of this important point, placing too much emphasis on the use of testing while failing t o take the time to listen to their patients. Successful interviewing is for the most part dependent upon your already well developed communication skills. What follows is a framework for approaching patient complaints in a problem orie nted fashion. The patient initiates this process by describing a symptom. It fal ls to you to take that information and use it as a springboard for additional qu estioning that will help to identify the root cause of the problem. Note that th is is different from trying to identify disease states which might exist yet do not generate overt symptoms. To uncover these issues requires an extensive "Revi ew Of Systems" (a.k.a. ROS). Generally, this consists of a list of questions gro uped according to organ system and designed to identify disease within that area . For example, a review of systems for respiratory illnesses would include: Do y ou have a cough? If so, is it productive of sputum? Do you feel short of breath when you walk? etc. In a practical sense, it is not necessary to memorize an ext ensive ROS question list. Rather, you will have an opportunity to learn the rele vant questions that uncover organ dysfunction when you review the physical exam for each system individually. In this way, the ROS will be given some context, i ncreasing the likelihood that you will actually remember the relevant questions. The patient's reason for presenting to the clinician is usually referred to as t he "Chief Complaint." Perhaps a less pejorative/more accurate nomenclature would be to identify this as their area of "Chief Concern." Getting Started: Always introduce yourself to the patient. Then try to make the environment as pr ivate and free of distractions as possible. This may be difficult depending on w here the interview is taking place. The emergency room or a non-private patient room are notoriously difficult spots. Do the best that you can and feel free to be creative. If the room is crowded, it's OK to try and find alternate sites for the interview. It's also acceptable to politely ask visitors to leave so that y ou can have some privacy. If possible, sit down next to the patient while conducting the interview. Remove any physical barriers that stand between yourself and the interviewee (e.g. put down the side rail so that your view of one another is unimpeded... though make sure to put it back up at the conclusion of the interview). These simple maneuv ers help to put you and the patient on equal footing. Furthermore, they enhance the notion that you are completely focused on them. You can either disarm or bui ld walls through the speech, posture and body languarge that you adopt. Recogniz e the power of these cues and the impact that they can have on the interview. Wh ile there is no way of creating instant intimacy and rapport, paying attention t o what may seem like rather small details as well as always showing kindness and respect can go a long way towards creating an environment that will facilitate the exchange of useful information. If the interview is being conducted in an outpatient setting, it is probably bet

ter to allow the patient to wear their own clothing while you chat with them. At the conclusion of your discussion, provide them with a gown and leave the room while they undress in preparation for the physical exam. Initial Question(s): Ideally, you would like to hear the patient describe the problem in their own wo rds. Open ended questions are a good way to get the ball rolling. These include: "What brings your here? How can I help you? What seems to be the problem?" Push them to be as descriptive as possible. While it's simplest to focus on a single , dominant problem, patients occasionally identify more then one issue that they wish to address. When this occurs, explore each one individually using the stra tegy described below. Follow-up Questions: There is no single best way to question a patient. Successful interviewing requi res that you avoid medical terminology and make use of a descriptive language th at is familiar to them. There are several broad questions which are applicable t o any complaint. These include: 1. Duration: How long has this condition lasted? Is it similar to a past prob lem? If so, what was done at that time? 2. Severity/Character: How bothersome is this problem? Does it interfere with your daily activities? Does it keep you up at night? Try to have them objective ly rate the problem. If they are describing pain, ask them to rate it from 1 to 10 with 10 being the worse pain of their life, though first find out what that w as so you know what they are using for comparison (e.g. childbirth, a broken lim b, etc.). Furthermore, ask them to describe the symptom in terms with which they are already familiar. When describing pain, ask if it's like anything else that they've felt in the past. Knife-like? A sensation of pressure? A toothache? If it affects their activity level, determine to what degree this occurs. For examp le, if they complain of shortness of breath with walking, how many blocks can th ey walk? How does this compare with 6 months ago? 3. Location/Radiation: Is the symptom (e.g. pain) located in a specific place ? Has this changed over time? If the symptom is not focal, does it radiate to a specific area of the body? 4. Have they tried any therapeutic maneuvers?: If so, what's made it better ( or worse)? 5. Pace of illness: Is the problem getting better, worse, or staying the same ? If it is changing, what has been the rate of change? 6. Are there any associated symptoms? Often times the patient notices other t hings that have popped up around the same time as the dominant problem. These te nd to be related. 7. What do they think the problem is and/or what are they worried it might be ? 8. Why today?: This is particularly relevant when a patient chooses to make m ention of symptoms/complaints that appear to be long standing. Is there somethin g new/different today as opposed to every other day when this problem has been p resent? Does this relate to a gradual worsening of the symptom itself? Has the p atient developed a new perception of its relative importance (e.g. a friend told them they should get it checked out)? Do they have a specific agenda for the pa tient-provider encounter? The content of subsequent questions will depend both on what you uncover and you r knowledge base/understanding of patients and their illnesses. If, for example, the patient's initial complaint was chest pain you might have uncovered the fol lowing by using the above questions: The pain began 1 month ago and only occurs with activity. It rapidly goes aw ay with rest. When it does occur, it is a steady pressure focused on the center of the chest that is roughly a 5 (on a scale of 1 to 10). Over the last week, it

has happened 6 times while in the first week it happened only once. The patient has never experienced anything like this previously and has not mentioned this problem to anyone else prior to meeting with you. As yet, they have employed no specific therapy. This is quite a lot of information. However, if you were not aware that coronary -based ischemia causes a symptom complex identical to what the patient is descri bing, you would have no idea what further questions to ask. That's OK. With addi tional experience, exposure, and knowledge you will learn the appropriate settin gs for particular lines of questioning. When clinicians obtain a history, they a re continually generating differential diagnoses in their minds, allowing the pa tient's answers to direct the logical use of additional questions. With each ste p, the list of probable diagnoses is pared down until a few likely choices are l eft from what was once a long list of possibilities. Perhaps an easy way to unde rstand this would be to think of the patient problem as a Windows-Based computer program. The patient tells you a symptom. You click on this symptom and a list of general questions appears. The patient then responds to these questions. You click on these responses and... blank screen. No problem. As yet, you do not hav e the clinical knowledge base to know what questions to ask next. With time and experience you will be able to click on the patient's response and generate a li st of additional appropriate questions. In the previous patient with chest pain, you will learn that this patient's story is very consistent with significant, s ymptomatic coronary artery disease. As such, you would ask follow-up questions t hat help to define a cardiac basis for this complaint (e.g. history of past myoc ardial infarctions, risk factors for coronary disease, etc.). You'd also be awar e that other disease states (e.g. emphysema) might cause similar symptoms and wo uld therefore ask questions that could lend support to these possible diagnoses (e.g. history of smoking or wheezing). At the completion of the HPI, you should have a pretty good idea as to the likely cause of a patient's problem. You may t hen focus your exam on the search for physical signs that would lend support to your working diagnosis and help direct you in the rational use of adjuvant testi ng. Recognizing symptoms/responses that demand an urgent assessment (e.g. crushing c hest pain) vs. those that can be handled in a more leisurely fashion (e.g. fatig ue) will come with time and experience. All patient complaints merit careful con sideration. Some, however, require time to play out, allowing them to either bec ome "a something" (a recognizable clinical entity) or "a nothing," and simply fa de away. Clinicians are constantly on the look-out for markers of underlying ill ness, historical points which might increase their suspicion for the existence o f an underlying disease process. For example, a patient who does not usually see k medical attention yet presents with a new, specific complaint merits a particu larly careful evaluation. More often, however, the challenge lies in having the discipline to continually re-consider the diagnostic possibilities in a patient with multiple, chronic complaints who presents with a variation of his/her "usua l" symptom complex. You will undoubtedly forget to ask certain questions, requiring a return visit t o the patient's bedside to ask, "Just one more thing." Don't worry, this happens to everyone! You'll get more efficient with practice. Dealing With Your Own Discomfort: Many of you will feel uncomfortable with the patient interview. This process is, by its very nature, highly intrusive. The patient has been stripped, both liter ally and figuratively, of the layers that protect them from the physical and psy chological probes of the outside world. Furthermore, in order to be successful, you must ask in-depth, intimate questions of a person with whom you essentially have no relationship. This is completely at odds with your normal day to day int eractions. There is no way to proceed without asking questions, peering into the life of an otherwise complete stranger. This can, however, be done in a way tha

t maintains respect for the patient's dignity and privacy. In fact, at this stag e of your careers, you perhaps have an advantage over more experienced providers as you are hyper-aware that this is not a natural environment. Many physicians become immune to the sense that they are violating a patient's personal space an d can thoughtlessly over step boundaries. Avoiding this is not an easy task. Lis ten and respond appropriately to the internal warnings that help to sculpt your normal interactions. A brief bit to sate your HPI interest Published Tuesday, January 24, 2006 by incidental findings. 0 comments The purpose of this blog is not to teach how to do an HPI, but since, by far, th at is the reason people are coming to this page, I will do a bit of education he re. This is not the trend. From now on, posts will continue as previous. When writing an HPI, the first sentence says it all. It should encompass a succi nct description of the patient and their complaint. It should be formulaic, such that you can do it with ease after being awake for the past 30 hours. It should roll off the tongue. Mr. P is a 58 y/o AA gentleman with PMH of DM2, HTN, hyper lipidemia, and CAD with CABG in 1997 who presents now with new onset chest pain for the past 1 day. Now, you need to elaborate. The essential elements of an HPI should include qual ity, location, duration, severity, timing, context, modifying factors, and assoc iated signs and symptoms. How this is presented is a matter of style. Some peopl e prefer a temporal linear train of thinking, such as Mr. P started having chest pain one night PTA (prior to admission) after eating a burrito, and his pain wa s initially a 5, substernal, and it slowly worsened throughout the course of the night. Most prefer to address the elements of the HPI in a systematic fashion. Mr. P's chest pain was a burning, substernal, non-radiating sensation, 5 out of 10 in in tensity, brought on by eating a burrito, constant and progressively worsening to 9/10... After fully describing his symptoms, a thorough review of RELEVANT history shoul d be included in the HPI. All relevant information should be presented initially . For instance, if this mythical Mr. P was a smoker and had a long family histor y of MI at an early age, several stentings done, that stuff needs to be presente d in the HPI. As well, pertinent positives AND NEGATIVES from the ROS should be done up front. And that is an HPI. Sounds easy, but takes a lot of practice. As long as I'm don e this, it's also worthwhile to talk about how to write an assessment and plan ( if you can identify me from the following, please keep it to yourselves and don' t be all "Hey, the guy who writes Incidental Findings is ________"). Personally, I feel an assessment and plan should go as follows: a summary of the patient, his past, his problem, his physical and labs/studies that relate to th e problem, his initial diagnosis, a reasonable differential. Then should come a diagnostic and therapeutic plan. Example. Mr. P is a 58 y/o AAM with DM2, HTN, CAD with CABG who presents now with atypica l chest pain, a benign physical exam except for SBP of 160, negative cardiac enz ymes and chest x-ray, and nonspecific ST changes on EKG. However, given his mult iple cardiac risk factors, MI cannot be excluded. Other possible causes include GERD, PE, or costochondritis. In order to further evaluate, we will obtain seria l cardiac enzymes, a comp panel to assess for metabolic derangement, a follow up EKG, and monitor the patient on telemetry. If his EKG, telemetry, or cardiac en

zymes show evidence of MI, then a diagnostic cardiac catheterization will be obt ained. If all studies are negative, a stress test is reasonable to evaluate for stress-related ischemic cardiac disease. In order to treat this patient, will ad minister prn NTG, ASA 325, oxygen, and maintain bedrest. If cardiac cath is indi cated, will consider PTCA at that time. prn Morphine will be ordered if chest pa in is uncontrolled, and NTG gtt and heparin gtt will be ordered if pt should sho w evidence of MI. This is just an example. But I find that following this logic really makes you t hink through your plan or care, and lets others understand your rationale for yo ur plan of care. Of course, if you're a shitty resident and don't have a plan, t hen forget this tutorial and continue being incompetent. History of the present illness From Wikipedia, the free encyclopedia Jump to: navigation, search In a medical encounter, a history of the present illness (abbreviated HPI)[1] (t ermed history of presenting complaint (HPC) in the UK) refers to a detailed inte rview prompted by the chief complaint or presenting symptom (for example, pain). Contents [hide] * * * * * * 1 2 3 4 5 6 Questions to include Acronyms Medicare definitions See also References External links

[edit] Questions to include Different sources include different questions to be asked while conducting an HP I, but in general they include the following: * * * * * * * Onset Location and radiation Severity and character/quality Duration and timing Precipitating and palliating factors Progression Associated symptoms

[edit] Acronyms Several acronyms have been developed to categorize the appropriate questions to include: * * * * * * * "OPQRST".[2][3] Alternatively, "PQRST".[4][5] See also Opqrst. "CLEARAST"[6] "LIQOR AAA"[7] "FAR COLDER" "OLD CART" "COLDSPA" "COLD REARS"

[edit] Medicare definitions The Centers for Medicare and Medicaid Services has published criteria for what c onstitutes a reimbursable HPI. A "brief HPI" constitutes one to three of the fol lowing elements:

* * * * * * * *

location quality severity duration timing context modifying factors associated signs & symptoms

A "extended HPI" includes four or more of these elements.[8][9] [edit] See also

HPI (history of present illness) Ask for: LIQOR AAA L I Q O R A A A Location of the symptom (forehead, wrist...) Intensity of the symptom (scale 1-10, 6/10) Quality of the symptom (burning, pulsating pain...) Onset of the symptom + precipitating factors Radiation of the symptom ( to left shoulder and arm) Associated symptoms ( palpitations, shortness of breath) Alleviating factors (sitting with my chest on my knees) Aggravating factors (effort, smoking, large meals)

PMH (past medical history) Search for: PAM HUGS FOSS P Previous presence of the symptom (same chief complaint) A Allergies (drugs, foods, chemicals, dust ...) M Medicines (any drugs the patient used) H U G S F O S S Hospitalization for any illness in the past Urinary changes ( esp if diabetic, elderly...) Gastrointestinal complains (diet changes, bowel movements...) Sleep pattern (waking up/going to sleep...) Family OB/GYN Sexual Social history (simmilar chief complaints/serious illness) history (LMP, abortions, para...) habits (active/preferences/STD...) life (job/house/smoking/alcohol.....)

history of present illness, an account obtained during the interview with the patient of the onset, duration , and character of the present illness, as well as of any acts or factors that a ggravate or ameliorate the symptoms. The patient is asked what he or she conside rs to be the cause of the symptoms and whether a similar condition has occurred in the past. See also health history. Mosby's Medical Dictionary, 8th edition. 2009, Elsevier. history of present illness Medical practice A chronologic description of the development of the Pt's presen t illness, from the 1st sign and/or Sx or from the previous encounter to the pre sent; HPI includes location, quality, severity, duration, timing, context, modif ying factors, and associated signs and Sx. See Evaluation and management service s. McGraw-Hill Concise Dictionary of Modern Medicine. 2002 by The McGraw-Hill Compa

nies, Inc.

Congestive Heart Failure History of Present Illness A 63-year-old male presents to the emergency room complaining of breathlessness for the past three days. Cardiac history is positive for a myocardial infarction three years ago followed by four-vessel coronary artery bypass surgery. The pat ient has been asymptomatic since surgery with no complaints of chest pain. Over the last three months PTA, the patient notes onset of shortness of breath w hile unloading groceries, walking stairs, and other strenuous ADLs. Two weeks ago, he was unable to complete his daily one-mile walk at the high sch ool track. He noted swelling in his feet and ankles. Four days PTA he woke at 2 am short of breath and had to sleep in his recliner the rest of the night. He ha s been unable to lay flat in bed at night since then and has slept on 3 pillows. Yesterday, he became breathless walking from one room to another. He presents t oday with extreme shortness of breath. He denies chest pain. http://medical-dictionary.thefreedictionary.com/history+of+present+illness/27/03 /2010 Past Medical History So Much History, So Little Time While not ideal, it is often necessary to perform a "quick and dirty" past medic al and minimal social history as part of a focused history and physical exam. Th is is particularly true in ambulatory care settings where new patients are seen for acute problems without the benefit of a thorough interview. The following is a suggested format for taking a brief past medical history in less than a minut e for the average patient. (Patients with multiple chronic problems will take lo nger.) The One Minute Past Medical History Allergies and Reactions to Drugs (What happened?) Current Medications (Including "Over-the-Counter") Medical/Psychiatric Illnesses (Diabetes, Hypertension, Depression, etc.) Surgeries/Injuries/Hospitalizations (Appendectomy, Car Accident, etc.) Immunizations Tobacco/Alcohol/Drug Use Reproductive Status for Females * Last Menstrual Period * Last Pelvic Exam/Pap Smear * Pregnancies/Births/Contraception 8. Birth History/Developmental Milestones for Children 9. Marital/Family Status 10. Occupation/Exposures Example Translation: Allergic to penicillin, Taking the medication Zantac, No major medi cal problems, Has had tubal ligation surgery, Unknown immunization status, Has s moked 1 pack per day for 10 years, Uses alcohol occasionally, No street drugs, L ast menstrual period 8/15/94 and normal, Last Pap smear 2 years ago and normal, Single heterosexual partner, Tubal for contraception, Has been pregnant twice an d delivered twice, Divorced, etc. 1. 2. 3. 4. 5. 6. 7.

Created: Version: Author: Location:

August 1, 1996 Modified: March 4, 1997 Copyright 1996 by the University of Florida Richard Rathe, MD / rrathe@dean.med.ufl.edu http://medinfo.ufl.edu/year1/bcs/interv/pmh.html

http://medinfo.ufl.edu/year1/bcs96/interv/pmh.html/27/03/2010

Medical history From Wikipedia, the free encyclopedia Jump to: navigation, search Not to be confused with History of medicine. The medical history or anamnesis[1][2] (abbr. Hx) of a patient is information ga ined by a physician by asking specific questions, either of the patient or of ot her people who know the person and can give suitable information (in this case, it is sometimes called heteroanamnesis), with the aim of obtaining information u seful in formulating a diagnosis and providing medical care to the patient. The medically relevant complaints reported by the patient or others familiar with th e patient are referred to as symptoms, in contrast with clinical signs, which ar e ascertained by direct examination on the part of medical personnel. Most healt h encounters will result in some form of history being taken. Medical histories vary in their depth and focus. For example, an ambulance paramedic would typical ly limit his history to important details, such as name, history of presenting c omplaint, allergies, etc. In contrast, a psychiatric history is frequently lengt hy and in depth, as many details about the patient's life are relevant to formul ating a management plan for a psychiatric illness. The information obtained in this way, together with clinical examination, enable s the physician to form a diagnosis and treatment plan. If a diagnosis cannot be made, a provisional diagnosis may be formulated, and other possibilities (the d ifferential diagnoses) may be added, listed in order of likelihood by convention . The treatment plan may then include further investigations to clarify the diag nosis. Contents [hide] * * * * * 1 2 3 4 5 Process Taking a medical history in the UK Review of systems See also References

[edit] Process A physician typically asks questions to obtain the following information about t he patient: * Identification and demographics: name, age, height, weight. * The "chief complaint (CC)" - the major health problem or concern, and its time course (e.g. chest pain for past 4 hours). * History of present illless (HPI) - details about the complaints, enumerate d in the CC. * Past Medical History (PMH) (including major illnesses, any previous surger y/operations, any current ongoing illness, e.g. diabetes). * Review of systems (ROS) Systematic questioning about different organ syste

ms * Family diseases - especially those relevant to the patient's chief complai nt. * Childhood diseases - this is very important in pediatrics. * Social history - including living arrangements, occupation, marital status , number of children, drug use (including tobacco, alcohol, other recreational d rug use), recent foreign travel, and exposure to environmental pathogens through recreational activities or pets. * Regular and acute medications (including those prescribed by doctors, and others obtained over-the-counter or alternative medicine) * Allergies - to medications, food, latex, and other environmental factors * Sexual history, obstetric/gynecological history, and so on, as appropriate . History-taking may be comprehensive history taking (a fixed and extensive set of questions are asked, as practised only by medical students) or iterative hypoth esis testing (questions are limited and adapted to rule in or out likely diagnos es based on information already obtained, as practised by busy clinicians). Comp uterised history-taking could be an integral part of clinical decision support s ystems. [edit] Taking a medical history in the UK Medical students are taught to follow a structured guide when learning how to ta ke a medical history on the wards : * Presenting complaint (PC): Ask the patient an open question, getting them to tell you what has happened: "Tell me what happened that made you come into ho spital today?" The PC should be recorded in the patient's own words, eg. "could not catch my breath" rather than "dyspnoea". * History of presenting complaint (HPC): Getting more details about how ever ything started and how it progressed: When did this start? What happened next? H ave you had that before? * If the patient describes having pain, a helpful mnemonic to remember is SO CRATES: S - site, O - onset (gradual/sudden), C - character, R - radiation, A associations (other symptoms), T - timing/duration, E - exacerbating and allevia ting factors, S - severity (rate the pain on a scale of 1-10). * Another helpful mnemonic, common in emergency medicine in the US is OPQRST , sometimes extended to OPQRSTI-ASPN: O - onset, P - provocation/palliation, Q quality, S - severity, T - time, I - interventions, AS - associated signs, PN pertinent negatives.) * Another useful mnemonic that may be used to analyse any symptom is as foll ows: Site ,Radiation ,Character ,Severity ,Associated features,Precipitating fact ors,Aggravating factors ,Relieving factors ,Onset ,Progression ,Cessation ,Durat ion ,Periodicity To make is easy to remember, these features may be grouped together as follo ws: Position (site and radiation),Character, Quantity (severity) ,Transmission ( associated features transmitted from index symptom) ,Modifying factors (precipit ating, aggravating, relieving factors) ,Rate (onset, progression, cessation, dur ation- as it is related to timing the word rate is used),Rhythm (periodicity) This give the mnemonic Please Carefully Question This Method For Reliability and Resilience This method may be used for analysis of any symptom and in addition it may b e used for analysis of functions that are evaluated during physical examination (for example pulse, respiration, murmurs etc)

* Direct questioning is used to ask specific questions about the diagnosis y ou have in mind or exclude diagnoses on the differentials list. A review of the relevant system is done and associated risk factors are considered, as this woul d be a good time to ask pertinent questions. * Perform the Functional Enquiry/Systems Review to help uncover undeclared s ymptoms * Past medical history (PMH) and past surgical history (PSH): Ever been to h ospital before? (when, where, why, etc). Do you suffer from any illnesses or con ditions? Have you had any operations or procedures? Ask specifically about these diseases; another helpful mnemonic is JAM THREADS: J - jaundice A - anaemia & other haematological conditions M - myocardial infarction T H R E A D S tuberculosis hypertension & heart disease rheumatic fever epilepsy asthma & COPD diabetes stroke

* Drug history (DH): Do you take any (regular) medication? Tablets? Injectio ns? Any over the counter drugs? Any prescriptions? Any herbal remedies? Contrace ptive pill? Do you have any allergies? If none, record as NKDA (no known drug al lergies). * Family history (FH): Are your family in good health? Parents - alive & wel l, or cause of death? Grandparents? Children? Spouse? Some areas of the FH may n eed detailed questioning, eg. to determine if there is a significant FH of heart disease or cancer. Be TACTFUL when asking about a FH of malignancy: "I know thi s is difficult but it is important for us to have the correct information..." It may be useful to draw a family pedigree tree. * Social history (SH): Probe without prying! Who else lives with you? Occupa tion. Marital status. Spouse's job and health. Housing - house or apartment? sta irs, how many? Who visits - family, neighbours, GP, nurse? Any dependents? Mobil ity - walking aids needed? Who does the cooking and shopping? Is there anything the patient can't do due to illness? Note: it is often a good idea to get this i nformation from a patient's GP if for whatever reason you can not ask the patien t yourself. Alcohol, tobacco and recreational drugs - How much? How long? When d id you stop? Quantify alcohol intake in terms of units and smoking in terms of p ack-years. Note: patients frequently 'underestimate' how much they drink and smo ke, be inclined to double any quantities stated. A helpful mnemonic for this psy chosocial aspect is SAD LADDERS: S - Smoking A - Alcohol use D - Drug use L A A D D E R Living Situation Activities of Daily Living Anxiety Depression Diet Exercise Relationships

S - Sexual history S - Support http://en.wikipedia.org/wiki/Medical_history/saturday/27/03/2010