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

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  • History taking in medicine

    FenyvesiFenyvesi

    2016, September

  • Good morning,

    I am

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    Tams FENYVESI

  • History taking in medicineHistory taking in medicine

    Anamnesis Anamnesis

    TheThe mainmain purposepurpose:: toto gathergather allallbasicbasic informationinformation pertinentpertinent toto thethe

    FenyvesiFenyvesiTams FenyvesiTams Fenyvesi 33

    basicbasic informationinformation pertinentpertinent toto thethepatientspatients illnessillness,, andand thethe patientspatientsadaptationadaptation toto illnessillness..

    SearchSearch historyhistory takingtaking inin medicinemedicine:: veryvery manymany onon thethe publicpublic domaindomainAboutAbout 4747..000000..000000 onon 1111thth AugustAugust 20162016

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  • Session Structure

    1. Introduction and Describing Aim &Objectives2. Chief complaint3. History of present illness4. Past medical history

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    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

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    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?

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    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?

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  • 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?

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    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

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    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

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    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

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    what kind of impact does the illnnes

    bear on work, family, financial

    situation.

  • CommunicationCommunication isis thethe keykey toto aa

    successfulsuccessful interviewinterview..

    AskAsk questionsquestions freelyfreely..

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    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

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    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

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    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

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    IInquirynquiry:: additionaladditional questionquestion inin thetherelevantrelevant problemsproblems

    OObservationbservation::noticenotice......nonverbalnonverbalcommunicationcommunication (b(b..ll..))

    UUnderstandingnderstanding:: thethe patientspatients concernsconcerns

  • Beware!!!The management may have a

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    The management may have a different approach

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  • 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

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    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 introductionintroductionMrMr.. Smith,Smith, ImIm JohnJohn TaylorTaylor aamedicalmedical studentstudent.. IveIve beenbeen askedasked

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    medicalmedical studentstudent.. IveIve beenbeen askedaskedtoto interviewinterview andand examineexamine youyou..DearDear oror GrandpaGrandpa areare notnot toto bebeusedused..

  • 22.. StartStart withwith aa veryvery generalgeneral openopen--endedendedquestionquestion ee..gg.:.:WhatWhat problemproblem hashas broughtbrought youyou toto thethehospital?hospital?

    DoDo notnot startstart withwith readingreading ofof previouspreviousmedicalmedical reportsreports!!!!

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    medicalmedical reportsreports!!!!

    PersuePersue thethe problemsproblems withwith moremore specificspecificopenopen--endedended questionsquestions:: (e(e..gg..))TellTell 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?

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    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? DoDo youyou feelfeel itit

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    WhereWhere inin youryour back?back? DoDo youyou feelfeel ititanywhereanywhere else?else?

    22..QualityQuality::WhatWhat doesdoes itit feelfeel like?like? WasWas ititsharp,sharp, dulldull oror aching?aching?

  • 3.Quantity:3.Quantity:HowHow manymany pillspills dodo youyou use?use?WhatWhat dodo youyou meanmean byby aa lot?lot?

    44..ChronologyChronology::

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    44..ChronologyChronology::WhenWhen diddid youyou firstfirst noticenotice it?it? HowHowlonglong diddid itit last?last? HaveHave youyou hadhad thethepainpain sincesince thatthat time?time?

  • 5.Setting:5.Setting:DoesDoes itit everever occuroccur atat rest?rest? DoDoyouyou everever getget thethe painpain whenwhen youyou areareemotionallyemotionally upset?upset?

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    66..ProvocativeProvocative::WhatWhat seemsseems toto bringbring onon thethe pain?pain?

    77..PalliativePalliative::WhatWhat 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

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    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?

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    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 pts facial expressions,