History taking in medicine - Semmelweis ?· History taking in medicine ... Taking the history & Recording:…

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<ul><li><p>History taking in medicine</p><p>FenyvesiFenyvesi</p><p>2016, September</p></li><li><p>Good morning,</p><p>I am</p><p>FenyvesiFenyvesi 22</p><p>Tams FENYVESI</p></li><li><p>History taking in medicineHistory taking in medicine</p><p>Anamnesis Anamnesis </p><p>TheThe mainmain purposepurpose:: toto gathergather allallbasicbasic informationinformation pertinentpertinent toto thethe</p><p>FenyvesiFenyvesiTams FenyvesiTams Fenyvesi 33</p><p>basicbasic informationinformation pertinentpertinent toto thethepatientspatients illnessillness,, andand thethe patientspatientsadaptationadaptation toto illnessillness..</p><p>SearchSearch historyhistory takingtaking inin medicinemedicine:: veryvery manymany onon thethe publicpublic domaindomainAboutAbout 4747..000000..000000 onon 1111thth AugustAugust 20162016</p></li><li><p>FenyvesiFenyvesi</p></li><li><p>Session Structure</p><p>1. Introduction and Describing Aim &amp;Objectives2. Chief complaint3. History of present illness4. Past medical history</p><p>FenyvesiFenyvesi</p><p>5. Systemic enquiry6. Family history 7. Drug history8. Social history</p><p>http://www.slideshare.net/drnooruddin/history-taking-in-medicine-4169758 **</p></li><li><p>.Taking the history &amp; Recording:Taking the history &amp; Recording:</p><p>Always record personal details: name, age, address, sex, </p><p>Beware of sensitive data. </p><p>Maximal care of privacy</p><p>FenyvesiFenyvesi</p><p> sex, Ethnicity (!) an often debated issue (PC?), occupation, religion, marital status. Record date of examination **</p><p>Maximal care of privacy</p></li><li><p>O-P-Q-R-S-T</p><p> 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 </p><p>what caused it?what caused it?</p><p>FenyvesiFenyvesi</p><p>what caused it?what caused it?</p><p> PP : Provocation or Palliation: Does anything : Provocation or Palliation: Does anything make it feel better? Worse?make it feel better? Worse?</p><p>larrylentinolarrylentino</p></li><li><p>O-P-Q-R-S-T</p><p> QQ : Quality: What is the pain like? Sharp, dull, : Quality: What is the pain like? Sharp, dull, crushing, tearing?crushing, tearing?</p><p> RR : Region/Radiation: Where does it hurt? : Region/Radiation: Where does it hurt? Does the pain move anywhere?Does the pain move anywhere?</p><p>FenyvesiFenyvesi</p><p> 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?</p><p> 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?</p></li><li><p>SOAPSOAPSubjective: how patient feels/thinks about him. How does he look. Includes general appearance/condition of patient</p><p>Objective relevant points of patient complaints/vital sings, physical examination/daily weight,fluid balance,diet/laboratory investigation and </p><p>FenyvesiFenyvesi</p><p>balance,diet/laboratory investigation and interpretation</p><p>Plan about management, treatment, further investigation, follow up and rehabilitation</p><p>**</p><p>Assessment address each active problem after making a problem list. Make differential diagnosis.</p></li><li><p>What is spoken of as a clinical picture is</p><p>not just a photograph of a man sick in bed;</p><p>it is an impressionistic painting of the</p><p>FenyvesiFenyvesi 1010</p><p>patient surrounded by his home, his work,</p><p>his relations, his friends, his joys, sorrows,</p><p>hopes,and fears. (Peabody, 1927)</p></li><li><p>What the patient thinks is happening, </p><p>what kind of impact does the illnnes </p><p>FenyvesiFenyvesi 1111</p><p>what kind of impact does the illnnes </p><p>bear on work, family, financial </p><p>situation.</p></li><li><p>CommunicationCommunication isis thethe keykey toto aa</p><p>successfulsuccessful interviewinterview..</p><p>AskAsk questionsquestions freelyfreely..</p><p>FenyvesiFenyvesi 1212</p><p>AskAsk questionsquestions freelyfreely..</p><p>PermitPermit thethe patientpatient toto telltell his/herhis/her</p><p>storystory inin his/herhis/her ownown wordswords..</p></li><li><p>IfIf thethe storystory isis veryvery vaguevague useuse</p><p>directdirect questionsquestions:: HowHow</p><p>WhereWhere WhenWhen isis betterbetter</p><p>thanthan WhyWhy</p><p>FenyvesiFenyvesi 1313</p><p>thanthan WhyWhy</p><p>PatientsPatients likelike toto respondrespond toto</p><p>questionsquestions inin aa wayway thatthat willwill</p><p>satisfysatisfy thethe doctordoctor!!</p></li><li><p>Treat the patient with respect,</p><p>take care not to contradict the pt.</p><p>You should refrain from trying to </p><p>impose your own moral standards</p><p>FenyvesiFenyvesi 1414</p><p>impose your own moral standards</p><p>on the pt.</p></li><li><p>Remember the Remember the rule of five vowelsrule of five vowels</p><p>AAuditionudition:: listenlisten carefullycarefullyEEvaluationvaluation:: sortingsorting outout ofof relevantrelevantIInquirynquiry:: additionaladditional questionquestion inin thethe</p><p>FenyvesiFenyvesi 1515</p><p>IInquirynquiry:: additionaladditional questionquestion inin thetherelevantrelevant problemsproblems</p><p>OObservationbservation::noticenotice......nonverbalnonverbalcommunicationcommunication (b(b..ll..))</p><p>UUnderstandingnderstanding:: thethe patientspatients concernsconcerns</p></li><li><p>Beware!!!The management may have a </p><p>FenyvesiFenyvesi 1616</p><p>The management may have a different approach</p></li><li><p>FenyvesiFenyvesi 1717</p></li><li><p>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 </p><p>FenyvesiFenyvesi 1818</p><p>Flexible Flexible -- spontaneous spontaneous -- not not interrogatinginterrogating</p><p>It is a powerful diagnostic tool.It is a powerful diagnostic tool.</p></li><li><p>Conducting an interviewConducting an interview</p><p>1.1. GreetingGreeting andand introductionintroductionMrMr.. Smith,Smith, ImIm JohnJohn TaylorTaylor aamedicalmedical studentstudent.. IveIve beenbeen askedasked</p><p>FenyvesiFenyvesi 1919</p><p>medicalmedical studentstudent.. IveIve beenbeen askedaskedtoto interviewinterview andand examineexamine youyou..DearDear oror GrandpaGrandpa areare notnot toto bebeusedused..</p></li><li><p>22.. StartStart withwith aa veryvery generalgeneral openopen--endedendedquestionquestion ee..gg.:.:WhatWhat problemproblem hashas broughtbrought youyou toto thethehospital?hospital?</p><p>DoDo notnot startstart withwith readingreading ofof previouspreviousmedicalmedical reportsreports!!!!</p><p>FenyvesiFenyvesi 2020</p><p>medicalmedical reportsreports!!!!</p><p>PersuePersue thethe problemsproblems withwith moremore specificspecificopenopen--endedended questionsquestions:: (e(e..gg..))TellTell meme moremore aboutabout youryour chestchest painpain..</p></li><li><p>3.3. Direct questionsDirect questions to specific to specific facts learned during the openfacts learned during the open--ended questions:ended questions:</p><p>where?where?</p><p>FenyvesiFenyvesi 2121</p><p>where?where?when?when?</p><p>how?how?</p></li><li><p>\\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::</p><p>1.Bodily location1.Bodily location::WhereWhere inin youryour back?back? DoDo youyou feelfeel itit</p><p>FenyvesiFenyvesi 2222</p><p>WhereWhere inin youryour back?back? DoDo youyou feelfeel ititanywhereanywhere else?else?</p><p>22..QualityQuality::WhatWhat doesdoes itit feelfeel like?like? WasWas ititsharp,sharp, dulldull oror aching?aching?</p></li><li><p>3.Quantity:3.Quantity:HowHow manymany pillspills dodo youyou use?use?WhatWhat dodo youyou meanmean byby aa lot?lot?</p><p>44..ChronologyChronology::</p><p>FenyvesiFenyvesi 2323</p><p>44..ChronologyChronology::WhenWhen diddid youyou firstfirst noticenotice it?it? HowHowlonglong diddid itit last?last? HaveHave youyou hadhad thethepainpain sincesince thatthat time?time?</p></li><li><p>5.Setting:5.Setting:DoesDoes itit everever occuroccur atat rest?rest? DoDoyouyou everever getget thethe painpain whenwhen youyou areareemotionallyemotionally upset?upset?</p><p>FenyvesiFenyvesi 2424</p><p>66..ProvocativeProvocative::WhatWhat seemsseems toto bringbring onon thethe pain?pain?</p><p>77..PalliativePalliative::WhatWhat dodo youyou dodo toto makemake itit better?better?</p></li><li><p>Question types to be Question types to be avoidedavoided</p><p>11..YesYes oror nono questionquestion inin generalgeneralproblemsproblems::</p><p> isis youryour workwork satisfying?satisfying?</p><p>TheThe patientpatient maymay wantwant toto pleaseplease thethe</p><p>FenyvesiFenyvesi 2525</p><p>TheThe patientpatient maymay wantwant toto pleaseplease thethedoctordoctor</p><p>22.. SuggestiveSuggestive questionquestion::DoDo youyou feelfeel thethe painpain inin youryour leftleftarm,arm, whenwhen youyou getget itit inin youryour chest?chest?</p></li><li><p>(avoid)(avoid)3.Why question:3.Why question:</p><p>They may carry tones of They may carry tones of accusation.accusation.Why did you wait so long?Why did you wait so long?</p><p>FenyvesiFenyvesi 2626</p><p>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?</p><p>5.Medical terms in question5.Medical terms in question::Did you have a paraparesis?Did you have a paraparesis?</p></li><li><p>Do not write extensive notes during</p><p>the interview, it distracts you from </p><p>observing the pts facial expressions,</p><p>FenyvesiFenyvesi 2727</p><p>observing the pts facial expressions,</p><p>body language,</p><p>Not even on your tablet!</p></li><li><p>Next stepNext stepSilence Silence -- 2 minutes2 minutes</p><p>What are you thinking about?What are you thinking about?</p><p>FenyvesiFenyvesi 2828</p><p>You are sayingYou are saying</p><p>FacilitationFacilitation</p><p>Verbal or nonVerbal or non--verbalverbal</p></li><li><p>ConfrontationConfrontationWhy are you so silent?Why are you so silent?You look upset.You look upset.</p><p>InterpretationInterpretation</p><p>FenyvesiFenyvesi 2929</p><p>InterpretationInterpretationYou seem to be quite happy You seem to be quite happy about that.about that.</p></li><li><p>SupportSupportI understand.I understand.</p><p>ReassuranceReassuranceYou are improving steadily.You are improving steadily.</p><p>EmpathyEmpathy</p><p>FenyvesiFenyvesi 3030</p><p>EmpathyEmpathyIt is understanding, not an It is understanding, not an emotional state of sympathy.emotional state of sympathy.</p></li><li><p>Be aware of the patient who asks,</p><p>I have a friend with., what do you</p><p>think about..? The question is </p><p>probably related to the pts own concerns. </p><p>FenyvesiFenyvesi 3131</p><p>probably related to the pts own concerns. </p></li><li><p>The doctor may also learn more about the illness from the way the patient tells the story than from the story itself</p><p>James B. Herrick</p><p>FenyvesiFenyvesi 3232</p><p>James B. Herrick1861-1954</p></li><li><p>FenyvesiFenyvesi</p></li><li><p>Each patient brings a different challenge: silent overtalkative seductive angry</p><p>FenyvesiFenyvesi 3434</p><p> angry insatiable ingratiating aggressive help rejecting demanding</p></li><li><p>Format of the historyFormat of the history</p><p>SourceSource andand reliabilityreliabilityPatientPatient oror else?else? heterohetero--anamnesisanamnesis</p><p>ChiefChief complaintcomplaint</p><p>FenyvesiFenyvesi 3535</p><p>ChiefChief complaintcomplaintTheThe patientspatients briefbrief statementstatement whywhyhe/shehe/she soughtsought medicalmedical attentionattention..</p><p>HistoryHistory ofof presentpresent illnessillnessWhat,What, when,when, how,how, where,where, which,which, whowhoandand whywhy</p></li><li><p>Past medical historyPast medical historyGeneral state of healthGeneral state of healthPast illnessesPast illnessesHospitalizationsHospitalizationsInjuriesInjuries</p><p>FenyvesiFenyvesi 3636</p><p>InjuriesInjuriesSurgerySurgeryAllergiesAllergiesImmunisationsImmunisations</p></li><li><p>Substance abuse*Substance abuse*DietDietSleep patternsSleep patternsCurrent medicationCurrent medication</p><p>*In Hungary the most common *In Hungary the most common </p><p>FenyvesiFenyvesi 3737</p><p>*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</p><p>question on smoking.question on smoking.</p></li><li><p>FenyvesiFenyvesi 3838</p></li><li><p>The WHO long ago suggested:</p><p>to increase the price of cigarettes,mostly by excise tax policyto radically change the outlook of cigarette</p><p>FenyvesiFenyvesi</p><p>to radically change the outlook of cigaretteboxes</p><p>show the harmabandon the enticing brand name</p></li><li><p>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 </p><p>down on your drinking?down on your drinking?Have people Have people aannoyednnoyed you by you by </p><p>criticising your drinking?criticising your drinking?</p><p>FenyvesiFenyvesi 4040</p><p>criticising your drinking?criticising your drinking?Have you ever feltHave you ever felt gguilty about uilty about </p><p>your drinking?your drinking?Have you ever taken a morning Have you ever taken a morning </p><p>eeyeye--opener to steady your opener to steady your nerves?nerves?</p></li><li><p>Other drug abuse, intoxicationvery delicate problem,with tactful and often specialapproach</p><p>FenyvesiFenyvesi</p><p>approach</p></li><li><p>FenyvesiFenyvesi</p></li><li><p>Occupational and environmental Occupational and environmental historyhistoryExposure to diseaseExposure to disease--producing producing substancessubstancesMore than just listing the jobsMore than just listing the jobs</p><p>FenyvesiFenyvesi 4343</p><p>More than just listing the jobsMore than just listing the jobsdurationdurationprotective devices?protective devices?medical screening?medical screening?</p></li><li><p>Biographical informationBiographical informationFamily historyFamily history</p><p>Information about the healthInformation about the health</p><p>FenyvesiFenyvesi 4444</p><p>of of the the entire familyentire familydiseases in the familydiseases in the family</p></li><li><p>Genetic implicationGenetic implicationhypertensionhypertensiondiabetesdiabetesMIMI</p><p>Psychosocial historyPsychosocial history</p><p>FenyvesiFenyvesi 4545</p><p>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)</p></li><li><p>Review of systemsReview of systems</p><p>ItIt allall thethe manymany symptomssymptoms thatthat maymay havehavebeenbeen overlookedoverlooked inin thethe historyhistory ofofpresentpresent illnessillness andand inin thethe pastpast medicalmedicalhistoryhistory..</p><p>FenyvesiFenyvesi 4646</p><p>historyhistory..ItIt isis bestbest organizedorganized fromfrom thethe headhead downdowntoto thethe extremitiesextremities..TheseThese questionsquestions shouldshould bebe askedasked inin aawayway thatthat thethe patientpatient couldcould answeranswer justjustyesyes oror nono.. WeWe needneed furtherfurtherquestioningquestioning inin casecase ofof yesyes..</p></li><li><p>At this phase it is best to have a checklist.Customize clinical narrative to</p><p>FenyvesiFenyvesi 4747</p><p>Customize clinical narrative toelectronic medical record</p><p>(EMC)</p></li><li><p>An informative example:An informative example:CardiacCardiac</p><p>High blood pressureHigh blood pressurePainPainPalpitationsPalpitations</p><p>FenyvesiFenyvesi 4848</p><p>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</p></li><li><p>Other ? for heart functionOther ? for heart functionFatigueFatigueEdemaEdema</p><p>FenyvesiFenyvesi 4949</p><p>EdemaEdemaCyanosisCyanosi...</p></li></ul>