Transcript History Taking

The History
Always remember the
golden rule…[Being Logic
and Chronologic]
The Sequence of the Interview
Greeting the patient and establishing
rapport
 Inviting the patient’s story
 Establishing the agenda for the interview
 Expanding and clarifying while testing
hypotheses
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The Sequence of the Interview
Creating a shared understanding of the
problem
 Negotiating a plan for evaluation and
treatment
 Patient education
 Planning for follow-up and closing the
interview
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The Medical History
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Personal History
Social History
Chief complaint
Past Medical History
Preliminary Data
Medications
Allergies
Family History
History of the Present Pregnancy / Illness
The concept of the preliminary data
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Do you still remember being logic and
chronologic?
The Chief Complaint
This is the main reason that the patient
sought help today.
 To elicit the chief complaint, ask broad
questions:
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– What brings you in today?
– Tell me what has been going on.
– Tell me how can I help you?
Chief Complaint…
So far that you are taking the history
from a female, Always find an answer to
the question: Is she pregnant or NOT?
 Chief complaint starts at the point of
time when the lady was symptom free
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Chief Complaint Example
Doctor: Hello, Mrs.Samara, what brings
you in today?
 Patient: I am having this problem with
my menses.
 Doctor: Tell me more about it.
 Patient: Its like my menses are starting
to come earlier than I expect and are
becoming heavier.
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Chief Complaint Example, (contd.)
Doctor: Anything else about the
menses?
 Patient: Well, they are becoming more
and more painful.
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Chief Complaint Description
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“This is a 27 year old teacher
complaining of recent onset of changes
in her menses which are becoming
more frequent, heavier and associated
with more pain.”
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Give me another suggestion….
Chief Complaint
The initial chief complaint may not be
the “true” reason that the patient came
in.
 If you uncover another reason for the
patient coming in you can include that in
your chief complaint.
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Chief complaint
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Why does a patient seek care?
– Unbearable symptoms
– Anxiety about the meaning of the
symptoms
– They have another problem they are
unaware of or embarrassed to reveal
– They are in a life crisis.
Past Medical History
– General state of health
– Chronic medical problems
– Hospitalizations
– Surgical history
– History of trauma
– Childhood illnesses
– Health maintenance
Past Medical History
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Eliciting the Past Medical History
– How would you describe your health?
– Are you having any other problems with
your health?
– Do you have any other medical problems?
– Are you treated for any other medical
conditions?
• You may learn more about this with
medications.
Past Medical History
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Medical Problems
– Chronic problems like:
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Diabetes mellitus
Hypertension
Chronic back pain
Depression
Coronary artery disease or MI
Congestive heart failure
Past Medical History
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Medical Problems
– You can’t always accept the patient’s
diagnosis, use records to confirm
– Are any of these problems active?
Past Medical History
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Childhood Illnesses
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Birth defects, ex., undescended testicle
Attention deficit
Drug use
Anorexia
Athlete
Meningitis
For Pediatrics information about the birth is
important
Past Medical History
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Hospitalizations
When?
Where?
Why?
For how long?
Past Medical History
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Surgical History
What part of the body?
Why?
When?
Where?
Any complications?
Reactions to anesthesia?
Past Medical History
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Trauma
What part of the body?
How injured?
Where hospitalized?
Past Medical History
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Reproductive History
– Menstruation
• Start
• Length and frequency
– Pregnancies
• G = Gravida=pregnancies
• P = Para = Live births
Birth Control
Health Maintenance
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Immunizations
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Screening Tests
Medications
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Medicine name
Purpose
Dose
Route
Frequency
Side effects
Taking as prescribed?
Cost issues
Medications
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Don’t forget!
– Over the counter medications
– Vitamins
– Nutritional supplements
Allergies
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Medications
– What is the reaction?
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Other substances, if severe reaction
– Ex. Peanut or bee sting allergy
Family History
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Genetic diseases
– Sickle cell anemia, cystic fibrosis
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Familial diseases
– Type 2 diabetes, breast cancer, what else?
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Psychiatric diseases
– Heriditary
– Affect patient’s psychosocial environment
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Contagious or Toxic
– Lead poisoning, influenza
Elements of the Patient Profile
 Topics
– Demographics
and Occupation
• Age, gender,
race, ethnic
group, religion,
marital status,
education,
occupation
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Typical Screening
Questions
– Now that I know
something about
your symptoms, tell
me a little about
yourself. All I know
is that you’re 53
years old and
married.
– What kind of work do
you do? What
exactly does that job
involve?
Elements of the Patient Profile
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Topics
– Lifestyle
• Nutrition and diet
• Daily activities
and exercise
• Cigarette, alcohol,
and drug use
Typical Screening
Questions
– Tell me a bit about
yourself.
– What is an average
day like for you?
– What’s your diet
like? Tell me what
you eat on an
average day.
– Do you have time for
regular exercise?
– Do you smoke
cigarettes?
Elements of the Patient Profile
 Topics
– Relationships
• Family and
household
composition
• Support system
• Marital and
other
significant
relationships
• Sexual history
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Typical Screening
Questions
– Now tell me about
your family. You’ve
been married how
long? Children?
– Any stresses or
problems with your
family?
– Any problems in your
marriage?
Demographics
Tell me about your background
(ethnicity/cultural beliefs)
 How far did you get in school?
 Do you ever have difficulty
reading/understanding labels on
medicines or other instructions?
 How would you describe your reading
ability?
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Occupational Survey
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Essentials of a Quick Occupational
Survey
– Do you work outside your home?
– What kind of work do you do?
– Tell me what that job is like for you.
– Is that what you’ve always done? What
other jobs have you held in the past?
Occupational Survey
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Essentials of a Quick Occupational
Survey
– Do you now - or did you in the past - have
exposure to fumes, chemicals, dust, loud
noise, radiation?
– Do you think anything at work (or at home)
is affecting your symptoms now? How
about stress at work?
– Do you have any financial stress (it’s
certainly very common these days)?
Lifestyle
Do you smoke, how much? Have you
ever tried to quit?
 How much alcohol do you drink?
 Tell me about your diet. What did you
eat yesterday?
 Are you happy with your current weight?
 Do you participate in regular exercise?
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Relationships
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Become more specific
– With whom do you live?
– How is your relationship with your son’s
father?
– What are some good and bad things about
your present relationship?
– What would you change?
Sexual History
Essential part of most patient’s life
experience (even parents and
grandparents)
 Sexual contact may be the source of
illness (HIV, Hepatitis B & C, Human
papillomavirus, etc.)
 Depression, anxiety, and anger may
relate to underlying sexual problems
 Many physical diseases or medications
lead to sexual dysfunction
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Asking the difficult questions
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Be supportive & encouraging
– make no assumptions - use term partner
– suppress any personal preferences/biases
– do not rush the interview and let the patient
clarify
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Following these suggestions, you will be
more likely to get honest answers
Beginning the Sexual History
A lot of men have sexual problems when
they take blood pressure medicine. Have
you noticed any problems?
 It sounds as though your marriage has
been a good one. How about your sexual
relationship?
 Many girls (boys) your age have questions
about sex and birth control. How about
you?
 Many people these days worry about
AIDS. Do you have any concerns about
being at risk for AIDS?
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Beginning the Sexual History
Do you have any questions or concerns
about sexuality or sexual functioning?
 Are you having any sexual problems?
 Many people who are ill experience a
change in their sexual function. Have
you noticed any change?
 Has your interest in sex changed
recently? Since you’ve been ill?
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Summary
Be genuine and encouraging
 Do not rush
 Get to know your patient’s
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– Demographics and Occupation
– Lifestyle
– Relationships
Menstrual History
This is the customary menstrual history
 Starts with menarche and ends with the
LMP
 Dates, Dates and Dates
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Past Obstetric History
Do you still remember being logic and
chronologic
 2-digit code
 5-digit code [G-TPAL]
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History of the present Illness
Vs
 History of the present pregnancy
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History of the Present Illness
In the “HPI” you will expand on the
patient’s chief complaint.
 This is a story of the patient’s problem.
 What has happened since they last felt
well?
 It should contain all the information you
need to form a differential diagnosis.
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History of the Present Illness, Ex.
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Ms. Fawkeya is a 27 year old pregnant
housewife with tingling and pain in her right
arm. She is in her eighth month of pregnancy
and has had an intermittent pain shooting
down from her right shoulder to her hand for
the last month. She rates it as 8 out of 10 in
severity at its worse . The pain is worse at
night, sometimes waking her from sleep. It
usually lasts for two or three hours.
Ms. Fawkeya (con.)
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The pain improves during the day and
sometimes resolves completely. Picking up
her 18 month old son makes it worse.
Shaking her hand improves it. She also has
a numbness in her right thumb, index and
middle fingers which is present with the pain
and persists for a few hours afterwards. She
has no weakness in the hand. She had the
same symptoms during her last pregnancy.
History of the Present Illness
Start general and become more
specific.
 Begin with open-ended questions as
you used to get the chief complaint
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– Tell me more about the pain.
– What else is going on?
– What was that like for you?
History of the Present Illness
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Use facilitating expressions to
encourage the patient to continue:
– Mmm Hmm.
– Yes?
– Uh Huh?
– And what else?
– Listening body language
HPI
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Once the patient has had a chance to
tell his or her story you can move on to
more directed questions to clarify.
– What is wrong?
– Where is it wrong?
– When did it start going wrong?
– How did it go wrong?
– Why do you think it is wrong?
HPI
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Directed or closed questions
– Multiple choice
• Do you have nausea, vomiting, constipation or
diarrhea?
• Is the pain sharp, dull or shooting?
• Have you had this for days, weeks or months?
• Pause to wait for each response.
HPI
– Yes or No questions
• Do you have diarrhea every day?
• Do you have any allergies?
– Quantitative questions
• How many loose stools do you have a day?
HPI
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Avoid leading questions
– You don’t smoke do you?
– You haven’t had any chest pain?
– Your wife is your only sexual partner, right?
HPI
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Avoid compound questions
– Do you have trouble sleeping? How much
sleep do you get?
– Do you use cocaine, marijuana or alcohol?
HPI
L: Location
 O: Other symptoms
 C: Characteristic of the symptom
 A: Aggravating or alleviating factors
 T: Timing
 E: Environment
 S: Severity
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HPI
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Location
– Where is the problem?
– Does it move or radiate?
HPI
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Other symptoms
– Pertinent positives and negatives to help
you rule in or rule out disease
– Associated symptoms
– Other new symptoms that may not be
related
HPI
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Characteristics
– Quality of the symptom
– Get the patient to use their own descriptive
words if possible
– What does it feel like?
HPI
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Aggravating and Alleviating Factors
– What makes it better?
– What makes it worse?
– What has the patient done to try to feel
better?
• Over the counter medications?
• Friend’s medication?
• Therapies?
HPI
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Timing
– When did it start?
– Is it intermittent or continuous?
– How long does each episode last?
– Does the symptom vary with time of day?
– Have you ever experienced this before?
HPI
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Environment
What places or events affect the symptom?
– Work vs. home
– Leisure activities
– Diet
– Emotions
– Heat, dust, altitude
HPI
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Severity
– How is the symptom interfering with the
patient’s daily functioning?
– If the patient has pain, how bad is the pain
on a scale of one to ten?
HPI
To get the LOCATES information move from the
general to the specific:
A 21 year old second year medical student in
excellent health comes in complaining of
abdominal pain.
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Patient: I have this terrible pain in my
stomach right here (pointing to the right lower
quadrant of her abdomen.)
 Doctor: Tell me more.
HPI Example
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Patient: Well, it’s a stabbing pain and it
started late last night. It just keeps getting
worse and worse. I just can’t get comfortable.
Doctor: Is there anything else going on?
Patient: I have completely lost my appetite
which is very unusual for me.
Doctor: Does anything make it better or
worse?
Patient: It really hurt riding in the car on the
way over here, especially going over bumps.
I feel best lying curled up in bed.
HPI
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Doctor: What were you doing when this
came on?
Patient: I had just come home after eating
dinner at my friend’s house.
Doctor: When was your last meal?
Patient: Dinner.
Doctor: When was your last bowel
movement?
Patient: Yesterday morning.
HPI
Doctor:
 Patient:
now.
 Doctor:
 Patient:
 Doctor:
 Patient:
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Have you had any nausea?
I am kind of nauseated right
Diarrhea?
No.
Vomiting?
No.
HPI
Doctor: Have you had a fever or chills?
 Patient: Not that I know of.
 Doctor: Have you had any pain when
you urinate?
 Patient: No.
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HPI
Doctor: How would you rate your pain
on a scale of one to ten if one is no pain
at all and ten is the worst pain you ever
had?
 Patient: Nine.
 Doctor: Ok, let me ask you some quick
questions about your past medical
history.
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