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Good morning,

I am

Tamás FENYVESI

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Good morning,

I am

Tamás FENYVESI

Tamás FenyvesiTamás Fenyvesi 33

The medical interviewThe medical interview

Anamnesis Anamnesis αναμνησις αναμνησις

The main purpose: to gather all The main purpose: to gather all basic informationbasic information pertinent to the pertinent to the patient’s patient’s illnessillness, and the patient’s , and the patient’s adaptation toadaptation to illness. illness.

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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

patient surrounded by his home, his work,

his relations, his friends, his joys, sorrows,

hopes,and fears. (Peabody, 1927)

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What the patient thinks is happening,

what kind of impact does the illnnes

bear on work, family, financial

situation.

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Communication is the key to a Communication is the key to a

successful interview.successful interview.

AskAsk questions questions freelyfreely..

PermitPermit the the patient to tellpatient to tell his/her his/her

story in his/her own words.story in his/her own words.

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If the story is very vague use If the story is very vague use

direct questions: “direct questions: “HowHow…” …”

““WhereWhere…” “…” “WhenWhen…” is better …” is better

than “than “WhyWhy…”…”

Patients like to respond to Patients like to respond to

questions in a way that will questions in a way that will

satisfy the doctorsatisfy the doctor!!

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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.

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

AAudition: listen carefullyudition: listen carefully

EEvaluation: sorting out of relevantvaluation: sorting out of relevant

IInquiry: additional question in the nquiry: additional question in the relevant problemsrelevant problems

OObservation:notice…...nonverbal bservation:notice…...nonverbal communication (b.l.)communication (b.l.)

UUnderstanding: the patient’s concernsnderstanding: the patient’s concerns

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Beware!!!The management may have a different approach

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The medical interview is the The medical interview is the basis of the basis of the good doctor-good doctor-patient relationshippatient relationship

Flexible - spontaneous - not Flexible - spontaneous - not interrogatinginterrogating

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

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Conducting an interviewConducting an interview

1.1. Greeting and introductionGreeting and introduction

““Mr. Smith, I’m John Taylor a Mr. Smith, I’m John Taylor a medical student. I’ve been asked medical student. I’ve been asked to interview and examine you.”to interview and examine you.”

““Dear” or “Grandpa” are not to be Dear” or “Grandpa” are not to be used.used.

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2.2. Start with a very general “Start with a very general “open-open-endedended” question e.g.:” question e.g.:““What problemWhat problem has brought you to the has brought you to the hospital?”hospital?”

Do not start with reading of previousDo not start with reading of previous medical reportsmedical reports!!!!

Persue the problems with Persue the problems with more specificmore specific open-ended questions:open-ended questions:““Tell me more about your chest pain.”Tell me more about your chest pain.”

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

where?where?

when?when?

how?how?

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\\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::

““Where in your back?” “Do you feel it Where in your back?” “Do you feel it anywhere else?”anywhere else?”

2.Quality:2.Quality:““What does it feel like?” “Was it What does it feel like?” “Was it sharp, dull or aching?”sharp, dull or aching?”

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3.Quantity:3.Quantity:““How many pills do you use?” How many pills do you use?” “What do you mean by a lot?”“What do you mean by a lot?”

4.Chronology4.Chronology::““When did you first notice it?” “How When did you first notice it?” “How long did it last?” “Have you had the long did it last?” “Have you had the pain since that time?”pain since that time?”

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5.Setting:5.Setting:““Does it ever occur at rest?” “Do Does it ever occur at rest?” “Do you ever get the pain when you are you ever get the pain when you are emotionally upset?”emotionally upset?”

6.Provocative6.Provocative::““What seems to bring on the pain?”What seems to bring on the pain?”

7.Palliative7.Palliative::““What do you do to make it better?”What do you do to make it better?”

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Question types to be Question types to be avoidedavoided

1.Yes or no1.Yes or no question question in general in general problemsproblems: :

” ” is your work satisfying?”is your work satisfying?”

The patient may want to please the The patient may want to please the doctordoctor

2. Suggestive question2. Suggestive question::““Do you feel the pain in your left Do you feel the pain in your left arm, when you get it in your chest?”arm, when you get it in your chest?”

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(avoid)(avoid)

3.Why question:3.Why question:They may carry tones of accusation.They may carry tones of accusation.

““Why did you wait so long?”Why did you wait so long?”

4.Multiple question4.Multiple question::

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

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

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

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Do not write extensive notes during

the interview, it distracts you from

observing the pt’s facial expressions,

b.l.

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Next stepNext step

Silence Silence - 2 minutes- 2 minutes

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

““You are saying…”You are saying…”

FacilitationFacilitation

Verbal or non-verbalVerbal or non-verbal

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

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

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SupportSupport

““I understand.”I understand.”

ReassuranceReassurance

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

EmpathyEmpathy

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

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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.

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

James B. Herrick1861-1954

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Each patient brings a different challenge:• silent• overtalkative• seductive• angry• insatiable• ingratiating• aggressive• help rejecting• demanding

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Format of the historyFormat of the history

Source and reliabilitySource and reliability

Patient or else? ‘hetero-anamnesis’Patient or else? ‘hetero-anamnesis’

Chief complaintChief complaint

The patient’s brief statement why The patient’s brief statement why he/she sought medical attention.he/she sought medical attention.

History of present illnessHistory of present illness

What, when, how, where, which, who What, when, how, where, which, who and whyand why

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

InjuriesInjuriesSurgerySurgeryAllergiesAllergiesImmunisationsImmunisations

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Substance abuse*Substance abuse*DietDietSleep patternsSleep patternsCurrent medicationCurrent medication

*In Hungary the most common *In Hungary the most common substance abuse is substance abuse is alcoholismalcoholism

and and smokingsmoking!! You must ask the!! You must ask the question on smoking.question on smoking.

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The best questionnaire as a tool for The best questionnaire as a tool for disclosing alcoholism is disclosing alcoholism is „„CAGECAGE””::

““Have you ever felt the need to Have you ever felt the need to ccutut down on your drinking?”down on your drinking?”

““Have people Have people aannoyednnoyed you by you by criticising your drinking?”criticising your drinking?”

““Have you ever feltHave you ever felt gguiltyuilty about about your drinking?”your drinking?”

““Have you ever taken a morning Have you ever taken a morning eeye-openerye-opener” to steady your ” to steady your nerves?”nerves?”

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

durationdurationprotective devices?protective devices?medical screening?medical screening?

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Biographical informationBiographical informationFamily historyFamily history

Information about the health of Information about the health of the the entire familyentire family

diseases in the familydiseases in the family

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Genetic implicationGenetic implication hypertension hypertension diabetes diabetes MIMI

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

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Review of systemsReview of systems

It Σ all the many symptoms that may have It Σ all the many symptoms that may have been overlooked in the history of present been overlooked in the history of present illness and in the past medical history.illness and in the past medical history.

It is best organized from the head down It is best organized from the head down to the extremities.to the extremities.

These questions should be asked in a These questions should be asked in a way that the patient could answer just way that the patient could answer just “yes” or “no”. We need further “yes” or “no”. We need further questioning in case of “yes”.questioning in case of “yes”.

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At this phase it is best to have a checklist.Customize clinical narrative toelectronic medical record (EMC)

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An informative example:An informative example:

CardiacCardiac

High blood pressureHigh blood pressurePainPainPalpitationsPalpitationsShortness 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

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Other ? for heart functionOther ? for heart functionFatigueFatigueEdemaEdemaCyanosisCyanosisHemoptysis (caughing up Hemoptysis (caughing up

blood)blood)

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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?”

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“ “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?”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?”

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““Does the pain occur at rest? … with Does the pain occur at rest? … with exertion?exertion?

… after eating? … when moving your arms? … after eating? … when moving your arms? … with emotional strain?… during … with emotional strain?… during sex?”sex?”

““Is the pain associated with shortness ofIs the pain associated with shortness ofbreath? … palpitations? … nausea orbreath? … palpitations? … nausea orvomiting? … coughing?... fever? … leg vomiting? … coughing?... fever? … leg

pain? coughing up blood?”pain? coughing up blood?”

““When was the last episode of your chestWhen was the last episode of your chestpain?”pain?”

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Common causes of chest painCommon causes of chest pain

CardiacCardiacCoronary artery diseaseCoronary artery diseaseAortic valvular diseaseAortic valvular diseasePulmonary artery hypertensionPulmonary artery hypertensionMitral valve prolapseMitral valve prolapsePericarditisPericarditisHOCM (hypertrophic obstructive HOCM (hypertrophic obstructive

cardiomyopathy)cardiomyopathy)

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VascularVascularDissection of the aortaDissection of the aorta

PulmonaryPulmonaryEmbolismEmbolism

PneumoniaPneumonia

PleuritisPleuritis

PTXPTX (pneumothorax) (pneumothorax)

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MusculosceletalMusculosceletalCostochondritis (Tietze’s syndrome)Costochondritis (Tietze’s syndrome)

ArthritisArthritis

Muscular spasmMuscular spasm

Bone tumorBone tumor

NeuralNeuralHerpes zosterHerpes zoster

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GastrointestinalGastrointestinalUlcerUlcer

Bowel diseaseBowel disease

Hiatal hernia (GERD)Hiatal hernia (GERD)

PancreatitisPancreatitis

CholecystitisCholecystitis

EmotionalEmotionalAnxietyAnxiety

DepressionDepression

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As you notice:

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

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Symptoms of heart failureSymptoms of heart failure I. I.

1. Respiratory signs- exertional breathlessness orthopnoe supine or sitting redistribution of blood volume pulmonary venous and capillary pressure paroxysmal nocturnal dyspnea-cardiac asthma 1.slow resorption of interstit fluid 2.expansion of thoracic blood volume 3.reduced adrenergic support in sleep 4.nocturnal depression of the resp. center pulmonary edema

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Symptoms of heart failureSymptoms of heart failure II. II.

2.fatigue and weakness hypoperfusion of the sceletal musculature hyponatremia caused by diuretics3.nocturia redistribution of cardiac output at night: RBF4.liver distension epigastrial dyscomfort

This leads you to….

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Class I —No limitation: Ordinary physical activity does not cause 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: 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 congestive failure are present even at rest. With any physical activity, increased discomfort is experienced.

NYHA Classification of HF

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

““ shut up, please !shut up, please !””

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The accuracy may be influenced in The accuracy may be influenced in different ways.different ways.

The history is not well enough The history is not well enough reproducible.reproducible.

1.1. Different physicians Different physicians askask the the questions in different way, and questions in different way, and interpretinterpret the answers differently. the answers differently.

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22 Patients often give frankly Patients often give frankly different different answers to the very same question.answers to the very same question.

studentstudent resident consultant resident consultant

(awkward situation)(awkward situation)

Careful use of Careful use of clear questionsclear questions is is essential.essential.

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At this stage :

review the documentation ofpast medical history

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

DIAGNOSIS!DIAGNOSIS!

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The written history is a summary of the The written history is a summary of the information obtained during the information obtained during the interview:interview:

Chief complaintChief complaint

History of present illnessHistory of present illness

Past medical historyPast medical history

Family historyFamily history

Psychosocial historyPsychosocial history

Review of systems (not in Review of systems (not in ppreprinted reprinted format)format)

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

It may serve as a guideline not It may serve as a guideline not to forget anything.to forget anything.

Questionnaires handed to the Questionnaires handed to the patient is not history taking!!patient is not history taking!!

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

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

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“ 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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Results about 4.020.000 entries for “medical history taking”

Reached 20 08 2008

If you wish to know a bit more: go to

Google

www.youtube.com/watch?v=u1x9M_S8fCw

a video example

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

Francis Weld PEABODY, 1881-1927