History taking in medicine

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2016, September

Good morning,

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Tamás FENYVESI

History taking in medicineHistory taking in medicine

Anamnesis Anamnesis ←←←←←←←← αναµνησιςαναµνησις

TheThe mainmain purposepurpose :: toto gathergather allallbasicbasic informationinformation pertinentpertinent toto thethe

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basicbasic informationinformation pertinentpertinent toto thethepatient’spatient’s illnessillness ,, andand thethe patient’spatient’sadaptationadaptation toto illnessillness ..

SearchSearch „„ historyhistory takingtaking inin medicine”medicine”:: veryvery manymany onon thethe publicpublic domaindomainAboutAbout 4747..000000..000000 onon 1111thth AugustAugust 20162016

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Session Structure

1. Introduction and Describing Aim &Objectives2. Chief complaint3. History of present illness4. Past medical history

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5. Systemic enquiry6. Family history 7. Drug history8. Social history

http://www.slideshare.net/drnooruddin/history-taking-in-medicine-4169758 **

.Taking the history & Recording:Taking the history & Recording:

Always record personal details: – name, – age, – address, – sex,

Beware of sensitive data.

Maximal care of privacy

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– sex, – Ethnicity (!) an often debated issue (PC?), – occupation, – religion, – marital status. – Record date of examination **

Maximal care of privacy

O-P-Q-R-S-T

�� Mnemonic device to help you remember Mnemonic device to help you remember questions you should ask to obtain a questions you should ask to obtain a patient history.patient history.–– OO : Onset: When did the problem begin and : Onset: When did the problem begin and

what caused it?what caused it?

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what caused it?what caused it?

–– PP : Provocation or Palliation: Does anything : Provocation or Palliation: Does anything make it feel better? Worse?make it feel better? Worse?

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O-P-Q-R-S-T

–– QQ : Quality: What is the pain like? Sharp, dull, : Quality: What is the pain like? Sharp, dull, crushing, tearing?crushing, tearing?

–– RR : Region/Radiation: Where does it hurt? : Region/Radiation: Where does it hurt? Does the pain move anywhere?Does the pain move anywhere?

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–– SS : Severity: On a scale of 1 to 10, how would : Severity: On a scale of 1 to 10, how would you rate your pain?you rate your pain?

–– TT : Timing of pain: Has the pain been constant : Timing of pain: Has the pain been constant or does it come and go? How long have you or does it come and go? How long have you had the pain?had the pain?

SOAPSOAPSubjective: how patient feels/thinks about him. How does he look. Includes general appearance/condition of patient

Objective – relevant points of patient complaints/vital sings, physical examination/daily weight,fluid balance,diet/laboratory investigation and

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balance,diet/laboratory investigation and interpretation

Plan – about management, treatment, further investigation, follow up and rehabilitation

Assessment – address each active problem after making a problem list. Make differential diagnosis.

What is spoken of as a ‘clinical picture’ is

not just a photograph of a man sick in bed;

it is an impressionistic painting of the

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patient surrounded by his home, his work,

his relations, his friends, his joys, sorrows,

hopes,and fears. (Peabody, 1927)

What the patient thinks is happening,

what kind of impact does the illnnes

bear on work, family, financial

situation.

CommunicationCommunication isis thethe keykey toto aa

successfulsuccessful interviewinterview ..

AskAsk questionsquestions freelyfreely ..

PermitPermit thethe patientpatient toto telltell his/herhis/her

storystory inin his/herhis/her ownown wordswords ..

IfIf thethe storystory isis veryvery vaguevague useuse

directdirect questionsquestions :: ““ HowHow……””

““ WhereWhere……”” ““ WhenWhen……”” isis betterbetter

thanthan ““ WhyWhy……””

PatientsPatients likelike toto respondrespond toto

questionsquestions inin aa wayway thatthat willwill

satisfysatisfy thethe doctordoctor !!

Treat the patient with respect,

take care not to contradict the pt.

You should refrain from trying to

impose your own moral standards

on the pt.

Remember the „Remember the „ rule of five vowelsrule of five vowels ””

AAuditionudition :: listenlisten carefullycarefullyEEvaluationvaluation :: sortingsorting outout ofof relevantrelevantIInquirynquiry :: additionaladditional questionquestion inin thethe

IInquirynquiry :: additionaladditional questionquestion inin thetherelevantrelevant problemsproblems

OObservationbservation ::noticenotice ……......nonverbalnonverbalcommunicationcommunication (b(b..ll..))

UUnderstandingnderstanding :: thethe patient’spatient’s concernsconcerns

Beware!!!The management may have a

The management may have a different approach

The medical interview is the The medical interview is the basis of the basis of the good doctorgood doctor--patient relationshippatient relationshipFlexible Flexible -- spontaneous spontaneous -- not not

Flexible Flexible -- spontaneous spontaneous -- not not interrogatinginterrogating

It is a powerful diagnostic tool.It is a powerful diagnostic tool.

Conducting an interviewConducting an interview

1.1. GreetingGreeting andand introductionintroduction““MrMr.. Smith,Smith, I’mI’m JohnJohn TaylorTaylor aamedicalmedical studentstudent.. I’veI’ve beenbeen askedasked

medicalmedical studentstudent.. I’veI’ve beenbeen askedaskedtoto interviewinterview andand examineexamine youyou..””“Dear”“Dear” oror “Grandpa”“Grandpa” areare notnot toto bebeusedused..

22.. StartStart withwith aa veryvery generalgeneral ““ openopen --endedended ””questionquestion ee..gg.:.:““ WhatWhat problemproblem hashas broughtbrought youyou toto thethehospital?”hospital?”

DoDo notnot startstart withwith readingreading ofof previouspreviousmedicalmedical reportsreports !!!!

medicalmedical reportsreports !!!!

PersuePersue thethe problemsproblems withwith moremore specificspecificopenopen --endedended questionsquestions:: (e(e..gg..))“Tell“Tell meme moremore aboutabout youryour chestchest painpain ..””

3.3. Direct questionsDirect questions to specific to specific facts learned during the openfacts learned during the open --ended questions:ended questions:

where?where?

where?where?when?when?

how?how?

\\Symptoms Symptoms (what the patient feels, (what the patient feels, e.g. pain)e.g. pain) are considered in the are considered in the classic classic „„seven dimensionsseven dimensions ”” ::

1.Bodily location1.Bodily location::

““WhereWhere inin youryour back?”back?” “Do“Do youyou feelfeel itit

““WhereWhere inin youryour back?”back?” “Do“Do youyou feelfeel ititanywhereanywhere else?”else?”

22..QualityQuality::“What“What doesdoes itit feelfeel like?”like?” “Was“Was ititsharp,sharp, dulldull oror aching?”aching?”

3.Quantity:3.Quantity:“How“How manymany pillspills dodo youyou use?”use?”“What“What dodo youyou meanmean byby aa lot?”lot?”

44..ChronologyChronology::

44..ChronologyChronology::“When“When diddid youyou firstfirst noticenotice it?”it?” “How“Howlonglong diddid itit last?”last?” “Have“Have youyou hadhad thethepainpain sincesince thatthat time?”time?”

5.Setting:5.Setting:“Does“Does itit everever occuroccur atat rest?”rest?” “Do“Doyouyou everever getget thethe painpain whenwhen youyou areareemotionallyemotionally upset?”upset?”

66..ProvocativeProvocative::“What“What seemsseems toto bringbring onon thethe pain?”pain?”

77..PalliativePalliative::“What“What dodo youyou dodo toto makemake itit better?”better?”

Question types to be Question types to be avoidedavoided

11..YesYes oror nono questionquestion inin generalgeneralproblemsproblems::

”” isis youryour workwork satisfying?”satisfying?”

TheThe patientpatient maymay wantwant toto pleaseplease thethe

TheThe patientpatient maymay wantwant toto pleaseplease thethedoctordoctor

22.. SuggestiveSuggestive questionquestion::““DoDo youyou feelfeel thethe painpain inin youryour leftleftarm,arm, whenwhen youyou getget itit inin youryour chest?”chest?”

(avoid)(avoid)3.Why question:3.Why question:

They may carry tones of They may carry tones of accusation.accusation.“Why did you wait so long?”“Why did you wait so long?”

4.Multiple question4.Multiple question::

“How many brothers and sisters “How many brothers and sisters you have and do they have…?”you have and do they have…?”

5.Medical terms in question5.Medical terms in question::

“Did you have a paraparesis?”“Did you have a paraparesis?”

Do not write extensive notes during

the interview, it distracts you from

observing the pt’s facial expressions,

body language,

Not even on your tablet!

Next stepNext stepSilence Silence -- 2 minutes2 minutes

“What are you thinking about?”“What are you thinking about?”

“You are saying…”“You are saying…”

FacilitationFacilitation

Verbal or nonVerbal or non--verbalverbal

ConfrontationConfrontation“Why are you so silent?”“Why are you so silent?”“You look upset.”“You look upset.”

InterpretationInterpretation

InterpretationInterpretation“You seem to be quite happy “You seem to be quite happy about that.”about that.”

SupportSupport“I understand.”“I understand.”

ReassuranceReassurance“You are improving steadily.”“You are improving steadily.”

EmpathyEmpathy

EmpathyEmpathyIt is understanding, not an It is understanding, not an emotional state of sympathy.emotional state of sympathy.

Be aware of the patient who asks,

“I have a friend with…., what do you

think about…..?” The question is

probably related to the pt’s own concerns.

“The doctor may also learn more about the illness from the way the patient tells the story than from the story itself”

James B. Herrick

James B. Herrick1861-1954

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Each patient brings a different challenge:• silent• overtalkative• seductive• angry

• angry• insatiable• ingratiating• aggressive• help rejecting• demanding

Format of the historyFormat of the history

SourceSource andand reliabilityreliabilityPatientPatient oror else?else? ‘hetero‘hetero--anamnesis’anamnesis’

ChiefChief complaintcomplaint

ChiefChief complaintcomplaintTheThe patient’spatient’s briefbrief statementstatement whywhyhe/shehe/she soughtsought medicalmedical attentionattention..

HistoryHistory ofof presentpresent illnessillnessWhat,What, when,when, how,how, where,where, which,which, whowhoandand whywhy

Past medical historyPast medical historyGeneral state of healthGeneral state of healthPast illnessesPast illnessesHospitalizationsHospitalizationsInjuriesInjuries

InjuriesInjuriesSurgerySurgeryAllergiesAllergiesImmunisationsImmunisations

Substance abuse*Substance abuse*DietDietSleep patternsSleep patternsCurrent medicationCurrent medication

*In Hungary the most common *In Hungary the most common

*In Hungary the most common *In Hungary the most common substance abuse is substance abuse is alcoholismalcoholismand and smokingsmoking!! You must ask the!! You must ask the

question on smoking.question on smoking.

The WHO long ago suggested:

to increase the price of cigarettes,mostly by excise tax policyto radically change the outlook of cigarette

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to radically change the outlook of cigaretteboxes

show the harmabandon the enticing brand name

The best questionnaire as a tool for The best questionnaire as a tool for disclosing alcoholismdisclosing alcoholism is is „„CAGECAGE””::“Have you ever felt the need to “Have you ever felt the need to ccut ut

down on your drinking?”down on your drinking?”“Have people “Have people aannoyednnoyed you by you by

criticising your drinking?”criticising your drinking?”

criticising your drinking?”criticising your drinking?”“Have you ever felt“Have you ever felt gguilty about uilty about

your drinking?”your drinking?”“Have you ever taken a morning “Have you ever taken a morning

eeyeye--opener” to steady your opener” to steady your nerves?”nerves?”

Other drug abuse, intoxicationvery delicate problem,with tactful and often specialapproach

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approach

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Occupational and environmental Occupational and environmental historyhistoryExposure to diseaseExposure to disease--producing producing substancessubstancesMore than just listing the jobsMore than just listing the jobs

More than just listing the jobsMore than just listing the jobsdurationdurationprotective devices?protective devices?medical screening?medical screening?

Biographical informationBiographical informationFamily historyFamily history

Information about the healthInformation about the health

of of the the entire familyentire familydiseases in the familydiseases in the family

Genetic implicationGenetic implicationhypertensionhypertensiondiabetesdiabetesMIMI

Psychosocial historyPsychosocial history

Psychosocial historyPsychosocial historyEducation, life style, sexual history (a Education, life style, sexual history (a very sensitive problem, very sensitive problem, the success the success depends very much on the gender of depends very much on the gender of doctor and patient)doctor and patient)

Review of systemsReview of systems

ItIt ΣΣ allall thethe manymany symptomssymptoms thatthat maymay havehavebeenbeen overlookedoverlooked inin thethe historyhistory ofofpresentpresent illnessillness andand inin thethe pastpast medicalmedicalhistoryhistory..

historyhistory..ItIt isis bestbest organizedorganized fromfrom thethe headhead downdowntoto thethe extremitiesextremities..TheseThese questionsquestions shouldshould bebe askedasked inin aawayway thatthat thethe patientpatient couldcould answeranswer justjust“yes”“yes” oror “no”“no”.. WeWe needneed furtherfurtherquestioningquestioning inin casecase ofof “yes”“yes”..

At this phase it is best to have a checklist.Customize clinical narrative to

Customize clinical narrative toelectronic medical record

An informative example:An informative example:CardiacCardiac

High blood pressureHigh blood pressurePainPainPalpitationsPalpitations

PalpitationsPalpitationsShortness of breath with exertionShortness of breath with exertionShortness of breath when lying flatShortness of breath when lying flatHistory of heart attackHistory of heart attackRheumatic feverRheumatic feverHeart murmurHeart murmurLast ECGLast ECG

Other ? for heart functionOther ? for heart functionFatigueFatigueEdemaEdema

EdemaEdemaCyanosisCyanosisHemoptysis (caughing up blood)Hemoptysis (caughing up blood)

Chest painChest pain“Where is the pain?”“Where is the pain?”“Does it radiate?” “Where?”“Does it radiate?” “Where?”

“For how long have you had the pain?”“For how long have you had the pain?”“Do you have recurrent episodes of “Do you have recurrent episodes of

pain?”pain?”

“What is the duration?”“What is the duration?”“How often do you get the pain?”“How often do you get the pain?”“What do you do to make it better?”“What do you do to make it better?”“What makes it worse? Breathing? Lying flat?“What makes it worse? Breathing? Lying flat?

moving your arms or neck?”moving your arms or neck?”“How would you describe the pain?”“How would you describe the pain?”

“How would you describe the pain?”“How would you describe the pain?”Let the patient describe it! And then ask:Let the patient describe it! And then ask:“burning?… pressing?… crushing?… dull?…“burning?… pressing?… crushing?… dull?…aching?… throbbing sharp?… constricting?…aching?… throbbing sharp?… constricting?…sticking?”sticking?”

“Does“Does thethe painpain occuroccur atat rest?rest? …… withwithexertion?exertion?

…… afterafter eating?eating? …… whenwhen movingmoving youryourarms?arms? …… withwith emotionalemotional strain?strain?…… duringduring

sex?”sex?”

“Is“Is thethe painpain associatedassociated withwith shortnessshortness ofofbreath?breath? …… palpitations?palpitations? …… nauseanausea ororvomiting?vomiting? …… coughing?coughing?...... fever?fever? …… leglegpain?pain? coughingcoughing upup blood?”blood?”

“When“When waswas thethe lastlast episodeepisode ofof youryour chestchestpain?”pain?”

Common causes of chest painCommon causes of chest pain

CardiacCardiacCoronary artery diseaseCoronary artery diseaseAortic valvular diseaseAortic valvular diseasePulmonary artery hypertensionPulmonary artery hypertension

Pulmonary artery hypertensionPulmonary artery hypertensionMitral valve prolapseMitral valve prolapsePericarditisPericarditisHOCM (hypertrophic obstructive HOCM (hypertrophic obstructive

cardiomyopathy)cardiomyopathy)

VascularVascularDissection of the aortaDissection of the aorta

PulmonaryPulmonaryEmbolismEmbolism

EmbolismEmbolismPneumoniaPneumoniaPleuritisPleuritisPTXPTX (pneumothorax)(pneumothorax)

MusculosceletalMusculosceletalCostochondritis (Tietze’s syndrome)Costochondritis (Tietze’s syndrome)ArthritisArthritisMuscular spasmMuscular spasm

Muscular spasmMuscular spasmBone tumorBone tumor

NeuralNeuralHerpes zosterHerpes zoster

GastrointestinalGastrointestinalUlcerUlcerBowel diseaseBowel diseaseHiatal hernia (GERD)Hiatal hernia (GERD)

PancreatitisPancreatitisCholecystitisCholecystitis

EmotionalEmotionalAnxietyAnxietyDepressionDepression

As you notice:

to put the right questions

you have to know the typical symptoms of the suspected disease!!e.g. heart failure:

Symptoms of heart failureSymptoms of heart failure I.I.

1. Respiratory signs-exertional breathlessnessorthopnoe supine or sitting

redistribution of blood volume pulmonary venous and capillary pressure

pulmonary venous and capillary pressureparoxysmal nocturnal dyspnea-cardiac asthma

1.slow resorption of interstit fluid 2.expansion of thoracic blood volume3.reduced adrenergic support in sleep4.nocturnal depression of the resp. center

pulmonary edema

Symptoms of heart failureSymptoms of heart failure II.II.

2.fatigue and weaknesshypoperfusion of the sceletal musculaturehyponatremia caused by diuretics

hyponatremia caused by diuretics3.nocturia

redistribution of cardiac output at night: RBF4.liver distension

epigastrial dyscomfort

This leads you to….

Class I—No limitation: Ordinary physical activity does notcause undue fatigue, dyspnea, or palpitation.

Class II —Slight limitation of physical activity:Such patients are comfortable at rest.Ordinary physical activity results in fatigue, palpitation dyspnea, or angina.

Class III —Marked limitation of physical activity:

NYHA Classification of HF

Class III —Marked limitation of physical activity:Although patients are comfortable at rest, less than ordinary activity will lead to symptoms.

Class IV —Inability to carry on any physical activity without discomfort: Symptoms of congestivefailure are present even at rest. With any physical activity, increased discomfort isexperienced.

Finally to end the interview Finally to end the interview tactfully (e.g.):tactfully (e.g.):

““ SHUT UP, PLEASE !SHUT UP, PLEASE !””

TheThe accuracyaccuracy maymay bebe influencedinfluenced inindifferentdifferent waysways..

TheThe historyhistory isis notnot wellwell enoughenoughreproduciblereproducible..

reproduciblereproducible..11.. DifferentDifferent physiciansphysicians askask thethe

questionsquestions inin differentdifferent way,way, andandinterpretinterpret thethe answersanswers differentlydifferently..

22 PatientsPatients oftenoften givegive franklyfrankly differentdifferentanswersanswers toto thethe veryvery samesame questionquestion..

studentstudent residentresident consultantconsultant

studentstudent residentresident consultantconsultant(awkward(awkward situation)situation)

CarefulCareful useuse ofof clearclear questionsquestions isisessentialessential..

At this stage :

review the documentation of

review the documentation ofpast medical history

History is the key to doctorHistory is the key to doctor--patient patient relationship and torelationship and to

DIAGNOSIS!DIAGNOSIS!

“ To study the phenomenon of disease

without books is to sail an uncharted sea,

while to study books without patients

is not to go sea at all”

William Osler

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“. . . For the secret of the care of thepatient is in caring for the patient.”

Francis Weld PEABODY, 1881-1927

TheThe writtenwritten historyhistory isis aa summarysummary ofof thetheinformationinformation obtainedobtained duringduring thetheinterviewinterview ::

Chief complaintChief complaintHistory of present illnessHistory of present illnessPast medical historyPast medical history

Family historyFamily historyPsychosocial historyPsychosocial historyReview of systems (not in Review of systems (not in ppreprinted reprinted format)format)

Problems of PCProblems of PC --based history based history taking:taking:

ItIt maymay serveserve asas aa guidelineguideline notnottoto forgetforget anythinganything ..QuestionnairesQuestionnaires handedhanded toto thethe

QuestionnairesQuestionnaires handedhanded toto thethepatientpatient isis notnot historyhistory taking!!taking!!

Robinson JD., Heritage J. Patient Education and Counseling 2006;60:279

History taking in medicine - Semmelweis...

Transcript of History taking in medicine - Semmelweis...

History taking in medicine - Semmelweis...

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