Transcript Mortality meeting

University of Aden
Faculty of medicine and health sciences
Department of surgery
History taking
in general surgery
Dr Tamimi
“It is a safe rule to have no teaching without a
patient for a text, and the best teaching is that
taught by the patient himself.”
William Osler – great clinician and medical educator
(1849-1919)
Patient-oriented studies have shown
that good patient-clinician
communication leads to :
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better clinical outcomes
less dissatisfaction
less malpractice achievement
Interviewing as a Clinical Skill
Like any other science, Clinical Medicine has
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Basic units of observation:
Symptom refers to what patient feels. Ex: headache, pain in
stomach
and
Sign refers to what examiner find. Ex: edema, ascites.
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Basic quantities of measurement
words and numbers
Basic instruments for obtaining these measurements
Ex: sphygmomanometer to measure blood pressure etc..
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But,
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The most important is the medical
history
Interviewing as a Clinical Skill
The science and art of interviewing require:
1.
2.
3.
4.
5.
Objectivity: with effective listening and responding
skills to obtain the primary symptom.
Precision: to obtain a well detailed information to
use in the diagnosis and treatment
Sensitivity: use of our interviewing skills to identify
real cases of illness.
Specificity : use of our interviewing skills to identify
real cases of wellness
Reliability: use of good interviewing skills to
enhance reproducibility.
Data Collection
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Product of history and physical examination
History
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Most important element of database
Accounts for more than 70% of the problem list
Physical examination
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Counts as 20-25% of database
Laboratory and other testing
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Accounts for less than 10% of database
Basic Principles
Communication
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Interviewer’s skill
Establish trust
Questions understandable to patient
Interpreter if necessary
Main purpose of interview
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Obtain basic information related to patient’s
illness or reason for visit
Basic Principles
Interviewer
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Cheerful, friendly, but respectful and concerned about the
patient
Novice interviewers
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Have to gain experience asking questions about subjects
that are more painful, delicate or unpleasant
Permit patient to express themselves in their own
words
Observe
body language for nonverbal clues
Listening
without interruption : is important and requires
skill.
 If you interrupt the patient you can
disrupt the patient’s train of thought
IN
GENERAL:
Listen more ,Talk less and Interrupt infrequently
Basic Principles
If patient gives a
vague history
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Ask more direct
questions
Listen without any
suggestion of
prejudice
Deal all patients with
respect
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Regardless of their age,
gender, beliefs,
intelligence, educational
background, legal status,
practices, culture, illness,
body habitus, emotional
condition, or economic
state
Basic Principles
Create an atmosphere of openness,
depends of:
Interviewer’s ability to be open and frank
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about topics that are distressing or
embarrassing to the interviewer, patient, or
both.
Promotes possibility of discussion those areas
Interviewer’s
appearance
Can influence success of interview
Basic Principles
Follow the “rule of five
vowels”
udition
bservation
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Listen carefully
nderstanding
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valuation
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Sort out relevant from
irrelevant data
nquiry
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Probe into significant
areas requiring more
clarification
Importance of nonverbal
communication
Regardless of what is said
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Of patient’s concerns and
apprehensions
Play empathetic role
Basic Principles
Touch
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May be useful
Communicates
warmth, affection,
caring, and
understanding
Be careful of cultural
variations
There is no need to
make a diagnosis out
of every bit of
information obtained
in an interview.
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If you cannot answer a
patient’s question, do
not.
Act as an advocate
for the patient
Basic Principles
The medical interview is a powerful diagnostic
tool if used properly
It is a blend of
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Cognitive and technical skills of interviewer
Feelings and personalities of both patient and
interviewer
Should be
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Flexible
Spontaneous
Not interrogative
Generally
Greet the patient
Adequately identify yourself and your
purpose
Allow patient’s privacy and comfort during
exam
Identify Yourself
Use Mr./ Mrs./ Ms (Patient’s name)
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formal address clarifies the professional nature of the
interview
Ex:
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I am a medical student working at (prof Altayyeb unit)
who has asked me to do an interview and general
examination for you. My name is …..
Avoid the following:
address the patient by their first name.
terms such as “Dear” or “Grandma”
Remember to
Follow these rules
Introduce your self
Take permission for the history
Record all data
Use common terms
Avoid nonstandard abbreviations
Be objective
Use diagrams where indicated
The interview setting
Interviewer and patient should be seated comfortably
at the same level.
Sit in a chair directly facing the patient in order to
make eye contact (distance 3-4 feet )
Consider ethnic/cultural influences
Not appropriate
Sitting on the bed or the exam table is too
familiar and not appropriate.
In general, sit at a distance of 3-4 feet.
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Distances of greater than five feet are impersonal and
distances closer than 3 feet interfere with the patient’s
“ private space”.
To write extensive notes or use a laptop
computer during the interview.
Basic interviewing techniques
Open- ended
Questions
For example:
“What problem
brought you to the
hospital today?”
Useful for
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opening the
interview
allows patient to tell
their story
spontaneously
does not presuppose
a specific answer
changing the topic to
be discussed
Direct questions
serves to classify
the areas
adds detail to the
story
can usually be
answered in one
word or a brief
sentence
Bodily location:
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Where are you felling the
pain?
Silence
Never use it with talkative patients and letting them to
control the interview.
When it is used correctly, it can indicate interest and
support.
Facilitation
Common verbal facilitations that we all use are
•“uh, huh”, “go on” or “tell me more about that”, “and
then”, etc.
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Non-Verbal facilitations:
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Nodding of the head
Hand gesture to continue
Looking interested
Questions to avoid
Multiple questions can confuse the patient
and lead to an incorrect response.
For example:
How many brothers and sisters do you have
with diabetes, tuberculosis, hypertension,
pneumonia or asthma?
Date of interview/examination
Identifying data:
Patient full name: Salim Abdella Ahmed Ba salih
Age ( date of birth)
Gender
Residency and origin
occupation
Marital status
Ethnic background
Religion
Source : self , mother , other identify
Reliability: reliable
Chief Complaint
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Note patient’s complaint in their own words
Chronological sequence
“abdominal pain for the past six months”
Vomiting 3 weeks
Abdominal distension 1 week
The chief complaint is like the “headline” in
a newspaper.
The History of Present Illness is the
“detailed story”.
History of Present Illness or HPI:
It refers to recent changes in health that led
the patient to seek medical attention at this
time
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It describes the information relevant to the chief
complaint
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Use chronological order to organize history
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Be very thorough
History of Present Illness:
A clear, chronological
events includes:
Onset of problem
Setting in which it
developed
Manifestations
Any treatments
Principal symptoms
described in terms of:
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Location
Quality
Quantity or severity
Timing (onset,
duration, frequency)
Setting
Factors that
aggravated or relieved
Associated
manifestations
HISTORY OF PRESENT ILLNESS
Mnemonic: OLD CART
HPI – “old cart”
“O” – onset
• “L” – location
• “D” – duration
•
“C” – character
• “A” – aggravating or
alleviating factors
• “R” – radiation of pain
• “T” - treatment
•
History of Present Illness:
Onset
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description of events coincident with onset
similar episodes in the past
It was gradual or sudden?
total duration of the symptom
History of Present Illness
Location
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Anatomic location
Quantity and quality of symptoms
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Ex: quality of the pain
sharp, dull, achy, etc.
Variations over time
History of Present Illness
Precipitating or Provoking factors:
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Activity at time of onset of symptoms
Correlate all episodes for common factors
Radiation
History of Present Illness
Severity
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Rate the severity of this episode on scale of 1 to 10 with 10
being the worst pain ever experienced
Rate beginning episode and severity now
Note any improvement or worsening
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Note severity of all appropriate complaints
History of Present Illness
Timing
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Duration of time for
each episode
Frequency of attacks
and recent changes
Treatment
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Relieving factors
includes medications,
rest (stopping activity),
and over the counter
treatments
History of Present Illness
Note Positives and
Negatives
Ex: abd pain
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Review of systems
questions for GI
ask about nausea,
vomiting or diarrhea,
melena, hematochezia
General items to note:
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patient’s ideas and
comments regarding
their symptoms
include any insights
patient has on their
problem
Any impact in daily life
The condition started ……..
Known case of diabetes or hypertension
Chronological manner
Past Medical History
Similar problem
Coronary arterial disease
MI
Hospitalisations
Blood transfusion
Any previous surgery
Systemic review
Concentrate on the system related
e.g. in obstructive jaundice ask about renal ,
hematological and CNS
REVIEW OF SYSTEMS
General: Obese or cachexic ,depressed .No fever,
chills or night sweats.
Skin: No rashes, pruritus( ask patient about itching,
but you write pruritus in the history), bruises or other
changes. No tattoos or piercing. No self-nevi
examinations.
Head: No history of head injury or loss of
consciousness; rare headaches described as “band
around head”; 1x/month, easily controlled with
medications
ROS
Eyes: Wears glasses for reading (prescription
unknown); no changes in vision recently;
Ears: Patient not aware of any problem hearing; no
dizziness, discharge, or pain present.
Nose: Occasional cold, two or three times a year,
lasting 3-5 days; no hay fever or current sinus
symptoms.
ROS
Mouth and Throat: Occasional sore throats
associated with colds; no difficulty in chewing or
eating; brushes and flosses twice a day; sees
dentist twice a year, no gingival bleeding.
ROS
Neck: No masses or tenderness.
Chest: History of occasional blood-tinged
sputum and cough in the morning when patient
was smoking,
No wheezing, history of asthma, bronchitis, or
tuberculosis.
ROS
Breasts: No masses or nipple discharge noted.
No visible changes on breast’s skin.
Cardiac: No orthopnea or paroxysmal nocturnal
dyspnea.
Vascular: No history of cerebrovascular
accidents or claudication.
ROS
Gastrointestinal: Recent decrease in appetite
with unintentional10 pound weight loss in past
few months; no nausea, vomiting, diarrhea or
constipation; uses no laxatives; no melena or
bleeding noted; no change neither bowel habits
nor stool size, no history of liver disease,
hepatitis, or gallbladder disease.
ROS
Genitourinary: Nocturia X 1. Urinates four to
five times a day; urine is light yellow in colour,
no dysuria, no history of urinary infections; no
history of STD (sexually transmitted disease).
ROS
Musculoskeletal: No arthralgias or myalgias; no
weakness or history of back problems; no
history of arthritis or gout.
Neurological: No history of seizures or
difficulties in walking or balance; no history of
motor or sensory deficits.
ROS
Endocrine: No known thyroid nodules, history of
temperature intolerance, hair changes,
polydipsia, polyphagia or polyuria.
Psychiatric: Depressed and very anxious about
his ill health; also anxious about the operation .
Medications( Drug history)
Any chronic or acute medication
Allergies
No known medicinal allergies or intolerances.
No food or latex allergies.
Family
History
Family History
Father, 75yrs, type 2 diabetes
Mother died, 64yrs, stomach cancer
Brother, 45yrs, heart attack at age 40yrs
Sister, 37yrs, alive and well
Son, 10yrs, alive and well
Wife, 41yrs, alive and well
Family
History
Family History
There is no family history of congenital disease.
No family history of breast cancer
No other history of diabetes or cardiac disease.
No history of renal, hepatic, or neurological
disease.
No history of mental illness or alcohol addiction.
Family History. Example
Father 52 y/o Hypertension
Mother 50 y/o Rheumatoid Arthritis
Sister 36 y/o good health
Brother 35 y/o good health
No family history of diabetes, cerebrovascular
accidents, renal disease, deafness, gout, other types
of arthritis, anemia, heart disease, mental illness,
alcoholism or drug addiction.
Maternal history of breast cancer; no other family
history of cancer.
Family History
Other relatives with heritable conditions can be
mentioned briefly as follows:
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Paternal history of colon cancer in 2 uncles.
Maternal history of renal cell carcinoma
No other family history of cancer;
No history of diabetes, Cerebro Vascular accidents (CVA),
arthritis, anemia, heart disease, alcoholism, or drug
addiction.
Obstetric and gynecological history
Pregnancy
CS
Cystocele or rectocele
Operations
SOCIAL HISTORY
Mr Mahfoodh was born and raised in
Hadramout, family moved to Aden,
Married and had children
Smoking , alcohol, chewing Qat
Tobacco , snuffer
House condition electricity and water
supply
Economic situation
Social History:
Note patient’s
marital status/history
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Married, widowed,
separated, single
If single, note if
there is a significant
other?
How is the
relationship?
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Note the quality of
the relationship
Note patient’s
occupation
Note where patient
was born & where
they grew up
Note important
experiences,
including upbringing,
school, military
service, work,
retirement
Social History
Note social, economic and standard of living
status.
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How do they pay their bills?
Who makes up their support system?
Ask specifically how job and daily life
satisfaction are.
Social History:
Note home situation and who lives there.
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Note significant friends or social support
Note highest level of education
Ask if patient has children & note their ages.
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Are the children adopted or biological?
Is there shared custody of children in divorced
families?
Summery
45 years old female with painless left
breast mass for three months , loss of
weight and positive family history of breast
cancer
Conclude by saying:
“Is there anything else that you would
like to tell me?
“Are there any questions you might like
to ask?”
Conclude by saying:
At the completion of the interview
 thank the patient for their cooperation
 and
Explain the patient that you are going to perform
a physical examination.
Let the patients to have time for the preparation
for it and offer them help.
The Poor Historian
An intern begins the presentation of the case in front
of the attending physicians, house officers and
students:
“Mr. Bilal is a 52 year-old man who presents with
abdominal pain, vomiting and fever.
The patient has been taking Panadol for the fever
and pain etc..
The patient is a poor historian …”
The Poor Historian
The attending physician learns that this sick
person claims to have a number of symptoms
and he is apparently taking several
medications.
The intern hastens to add that Mr. Bilal is noncompliant, he doesn’t seem to understand his
illness, and he is, after all, a “poor historian.”
The intern continues with the patient’s physical
findings and initial laboratory data.
The Poor Historian
Meanwhile, the attending physician reflects on the
meaning of the term “poor historian” and wonders
about the nature of this patient’s “poorness.”
He knows what the intern is trying to tell the group with
the phrase “poor historian”
But not, the intern is saying in precise medical
shorthand: “I was unable to reconstruct a logical story
of the illness in my conversation with this patient ’’. We
did not communicate well.”
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The attending physician concludes that
the term “poor historian” is appropriate,
but perhaps it applies to the intern, who
might be more correct in saying: “The
clinical history is unclear because I’m a
poor historian.”
Remember, its not what you find that
gets you in trouble.
ITS WHAT YOU MISS!
Thank you