History taking in medicine - Semmelweis...
Transcript of History taking in medicine - Semmelweis...
History taking in medicine
FenyvesiFenyvesi
2016, September
Good morning,
I am
FenyvesiFenyvesi 22
Tamás FENYVESI
History taking in medicineHistory taking in medicine
Anamnesis Anamnesis ←←←←←←←← αναµνησιςαναµνησις
TheThe mainmain purposepurpose :: toto gathergather allallbasicbasic informationinformation pertinentpertinent toto thethe
FenyvesiFenyvesiTamás FenyvesiTamás Fenyvesi 33
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
FenyvesiFenyvesi
Session Structure
1. Introduction and Describing Aim &Objectives2. Chief complaint3. History of present illness4. Past medical history
FenyvesiFenyvesi
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
FenyvesiFenyvesi
– 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?
FenyvesiFenyvesi
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?
larrylentinolarrylentino
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?
FenyvesiFenyvesi
–– 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
FenyvesiFenyvesi
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
FenyvesiFenyvesi 1010
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
FenyvesiFenyvesi 1111
what kind of impact does the illnnes
bear on work, family, financial
situation.
CommunicationCommunication isis thethe keykey toto aa
successfulsuccessful interviewinterview ..
AskAsk questionsquestions freelyfreely ..
FenyvesiFenyvesi 1212
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……””
FenyvesiFenyvesi 1313
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
FenyvesiFenyvesi 1414
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
FenyvesiFenyvesi 1515
IInquirynquiry :: additionaladditional questionquestion inin thetherelevantrelevant problemsproblems
OObservationbservation ::noticenotice ……......nonverbalnonverbalcommunicationcommunication (b(b..ll..))
UUnderstandingnderstanding :: thethe patient’spatient’s concernsconcerns
Beware!!!The management may have a
FenyvesiFenyvesi 1616
The management may have a different approach
FenyvesiFenyvesi 1717
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
FenyvesiFenyvesi 1818
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
FenyvesiFenyvesi 1919
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 !!!!
FenyvesiFenyvesi 2020
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?
FenyvesiFenyvesi 2121
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
FenyvesiFenyvesi 2222
““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::
FenyvesiFenyvesi 2323
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?”
FenyvesiFenyvesi 2424
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
FenyvesiFenyvesi 2525
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?”
FenyvesiFenyvesi 2626
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,
FenyvesiFenyvesi 2727
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?”
FenyvesiFenyvesi 2828
“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
FenyvesiFenyvesi 2929
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
FenyvesiFenyvesi 3030
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.
FenyvesiFenyvesi 3131
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
FenyvesiFenyvesi 3232
James B. Herrick1861-1954
FenyvesiFenyvesi
Each patient brings a different challenge:• silent• overtalkative• seductive• angry
FenyvesiFenyvesi 3434
• 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
FenyvesiFenyvesi 3535
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
FenyvesiFenyvesi 3636
InjuriesInjuriesSurgerySurgeryAllergiesAllergiesImmunisationsImmunisations
Substance abuse*Substance abuse*DietDietSleep patternsSleep patternsCurrent medicationCurrent medication
*In Hungary the most common *In Hungary the most common
FenyvesiFenyvesi 3737
*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.
FenyvesiFenyvesi 3838
The WHO long ago suggested:
to increase the price of cigarettes,mostly by excise tax policyto radically change the outlook of cigarette
FenyvesiFenyvesi
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?”
FenyvesiFenyvesi 4040
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
FenyvesiFenyvesi
approach
FenyvesiFenyvesi
Occupational and environmental Occupational and environmental historyhistoryExposure to diseaseExposure to disease--producing producing substancessubstancesMore than just listing the jobsMore than just listing the jobs
FenyvesiFenyvesi 4343
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
FenyvesiFenyvesi 4444
of of the the entire familyentire familydiseases in the familydiseases in the family
Genetic implicationGenetic implicationhypertensionhypertensiondiabetesdiabetesMIMI
Psychosocial historyPsychosocial history
FenyvesiFenyvesi 4545
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..
FenyvesiFenyvesi 4646
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
FenyvesiFenyvesi 4747
Customize clinical narrative toelectronic medical record
(EMC)
An informative example:An informative example:CardiacCardiac
High blood pressureHigh blood pressurePainPainPalpitationsPalpitations
FenyvesiFenyvesi 4848
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
FenyvesiFenyvesi 4949
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?”
FenyvesiFenyvesi 5050
“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?”
FenyvesiFenyvesi 5151
“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?”
FenyvesiFenyvesi 5252
“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
FenyvesiFenyvesi 5353
Pulmonary artery hypertensionPulmonary artery hypertensionMitral valve prolapseMitral valve prolapsePericarditisPericarditisHOCM (hypertrophic obstructive HOCM (hypertrophic obstructive
cardiomyopathy)cardiomyopathy)
VascularVascularDissection of the aortaDissection of the aorta
PulmonaryPulmonaryEmbolismEmbolism
FenyvesiFenyvesi 5454
EmbolismEmbolismPneumoniaPneumoniaPleuritisPleuritisPTXPTX (pneumothorax)(pneumothorax)
MusculosceletalMusculosceletalCostochondritis (Tietze’s syndrome)Costochondritis (Tietze’s syndrome)ArthritisArthritisMuscular spasmMuscular spasm
FenyvesiFenyvesi 5555
Muscular spasmMuscular spasmBone tumorBone tumor
NeuralNeuralHerpes zosterHerpes zoster
GastrointestinalGastrointestinalUlcerUlcerBowel diseaseBowel diseaseHiatal hernia (GERD)Hiatal hernia (GERD)
FenyvesiFenyvesi 5656
PancreatitisPancreatitisCholecystitisCholecystitis
EmotionalEmotionalAnxietyAnxietyDepressionDepression
As you notice:
to put the right questions
FenyvesiFenyvesi 5757
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
FenyvesiFenyvesi 5858
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
FenyvesiFenyvesi 5959
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
FenyvesiFenyvesi 6060
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 !””
FenyvesiFenyvesi 6161
““ SHUT UP, PLEASE !SHUT UP, PLEASE !””
TheThe accuracyaccuracy maymay bebe influencedinfluenced inindifferentdifferent waysways..
TheThe historyhistory isis notnot wellwell enoughenoughreproduciblereproducible..
FenyvesiFenyvesi 6262
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
FenyvesiFenyvesi 6363
studentstudent residentresident consultantconsultant(awkward(awkward situation)situation)
CarefulCareful useuse ofof clearclear questionsquestions isisessentialessential..
At this stage :
review the documentation of
FenyvesiFenyvesi 6464
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!
FenyvesiFenyvesi 6565
“ To study the phenomenon of disease
without books is to sail an uncharted sea,
while to study books without patients
FenyvesiFenyvesi 6666
is not to go sea at all”
William Osler
FenyvesiFenyvesi
“. . . For the secret of the care of thepatient is in caring for the patient.”
FenyvesiFenyvesi 6868
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
FenyvesiFenyvesi 6969
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
FenyvesiFenyvesi 7070
QuestionnairesQuestionnaires handedhanded toto thethepatientpatient isis notnot historyhistory taking!!taking!!
FenyvesiFenyvesi 7171
Robinson JD., Heritage J. Patient Education and Counseling 2006;60:279
FenyvesiFenyvesi 7272
Robinson JD., Heritage J. Patient Education and Counseling 2006;60:279