Transcript History Taking Process & Content.

History Taking: Content &
Process
Lao Clinical Science Family
Medicine Specialist Medical
Curriculum Communication
Course September 18 2006
Dr. Lanice Jones & Dr. Gwen Hollaar & Dr Bob Lee
Outline of the Course – 2 sessions
of Building an Elephant
3 Parts to the Elephant
Content – Easiest to Teach and
Learn: what we need to know about
the patient
Process – a little more difficult: What
questions to ask, and how to ask to
get the information that we need
Relationship Building: Developing the
Doctor-patient relationship
Medical Content
Patient Identification
Patients Concern
History of Present Illness
Past Medical History
Family History
Social History
Review of Systems
Summary
Problem List
Plan
Patient Identification
Name
Age
Address/Village
Patient Concern
Get the list of patient concerns at the
beginning of the interview
History of Present Illness
Get the details about the main symptoms.
For example: Symptom of pain
Where is the pain?
When does the patient have the pain?
What is the Quality of the pain?
What is the Quantity of the pain (how often)?
Aggravate – what makes the pain worse?
Alleviate – what makes the pain better?
Associated Symptoms – what other symptoms
are associated with this pain?
Belief: What does the patient think is going on?
History of Present Illness
To give examples of what to ask
about associated symptoms
Symptom: Cough
Ask further questions specifically about
fever, sputum, hemoptysis, weight loss,
anorexia, night sweats, ***eating uncooked
seafood
Symptom: abdominal pain
jaundice, nausea, vomiting, diarrhea, blood
in the stool
History of Present Illness
Why do we ask about what the patient
thinks or believes are causing their
symptoms?
Helps to identify the patient’s fear
Allows you to consider investigating and
treating that patient’s fear
Is a helpful way to develop a trusting
relationship with a patient
Past Medical History
Other medical problems the patient
has or had
Past hospitalizations and past
surgeries
Medications
Allergies
Pediatric: Pregnancy, Birth history,
Developmental Milestones,
Immunizations
Family History
Parents History: if died, how old and
what they died of
Illnesses in Brothers and Sisters
Illnesses in their children
May include extended family
members
Social History
Smoking (how long / how often)
Alcohol (how much)
Any other drug use
Who they live with
Occupation
Review of Systems
“Head to Toe” check-list of symptoms
If it is important to the history of
present illness, it belongs in there
The purpose of the ‘Review of
Systems’ is to identify any other
problems not mentioned or missed
Review of Systems
General: Weight loss/gain, appetite, night
sweats, fatigue
Head & Neck: headaches, ear or eye or
throat problems, difficulty swallowing
Respiratory: shortness of breath,
coughing, sputum (describe sputum)
Cardiac: palpitations, chest pain, ankle
swelling, shortness of breath when lying
down or at night
Gastrointestinal: abdominal pain, gas,
bloating, nausea, vomiting, diarrhea,
constipation, blood in the stool, jaundice
Urinary: frequency, dysuria, nocturia,
hesitancy, incontinence, +/- sexual
dysfunction
MSK: joint or limb pain, swelling, redness
Neuro: loss of function, numbness or
weakness
Patient Identification:
John Doe
36 y.o. man from Pakse farmer
Patient Concern: Cough & Hemoptysis
History of Present Illness:
2 month history of cough
Sputum contains streaks of blood
Cough is worse with smoking
Nothing improves the cough
Patient tried antibiotics with no relief
Associated symptoms: weight loss of 10 Kg, night sweats, anorexia,
fatigue, no chest pain
Past Medical History
Medical: no past medical problems
Surgery: no past surgery
Allergies: none
Medications: Took 10 days of cephalexin, no relief
Family History:
Mother finished TB Rx 2 months ago
Father alive and well
Other family members healthy
Social History:
Smokes about 8 cigarettes per day & has smoked for 16 years
Drinks Beer Lao 1 or 2 per day, Lao Lao at weddings
Married, 3 children
Review of Systems
Occasional headaches
Process – How to get the Patient’s
Information
Introduction: Introduce yourself and your
role, and if you are a student, explain who
your preceptor is
Ask an Open Ended Question to find out
the Current Concern:
Open Ended Questions – can not be
answered by 1 or 2 words
Closed Ended – can be answered by 1 or
two words: Do you have any headaches?
How long have you had the chest pain?
Process: Use Open Ended Questions to
Identify the Patient Concern
What is your concern today?
What is your problem today?
What would you like to discuss today?
What brought you to the doctor
today?
How can I help you today?
Process: Explain what you are
going to do next
Explain that you are going to ask
more questions about the patient’s
problem
Explain that you are going to ask
more questions about their medical
problems in the past, family medical
problems and about their life in
general
Explain that you will then examine the
patient after asking the questions
Process: Opening Questions for
History of Present Illness
Examples:
Can you start at the beginning, and tell
me all about your _________
(headache,cough, pain)
When were you last completely well?
Can you tell me all about what
symptoms you have had from then until
now?
Tell me everything about your headache.
Process: At the End of the History
of Present Illness
Give a summary, and ask if you’ve
understood correctly, or you may ask if
there is any more information the patient
might like to add.
(Some physicians do this at the very end of the
history taking instead)
Tell the patient that you are moving on to
ask more general questions about their
past medical history
Process: Ask the patient about Past
Medical History
Past Medical History
Medical
Surgical
Medications
Allergies to Medications or otherwise
Family History
Social History
System Review
Give me an example of a statement
that you could use to inform the
patient that you are going to ask them
questions to make sure there are no
other health problems
Now you’ve got your information
Give a Summary
Ask if you’ve understood the
information correctly
Ask if there is any other information
that the patient wants you to know
Advise what your plan would be
Check with the patient that they are in
agreement with your plan
When the intern gives you the history
after they have seen the patient, be
sure it is complete
Be consistent in the history that you
expect from the interns
They will only get better with more
and more practice!