general principles of gastroentorylogy

7/29/2019 General Principles Of gastroentorylogy.

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General principles of

history taking.


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Introduction.

The overall purpose of medical practice is to

relieve suffering. In order to achieve this

purpose, it is important to make a diagnosis,

to know how to approach treatment, and to

design an appropriate scheme of management

for each patient. It is therefore essential to

understand each person as fully as possible,whatever their social class or ethnic and

cultural background.


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The thorough doctor will not only elucidatethe problems posed by disease, but also applyhis or her skill to advise patients and families

how to manage these problems. Thedistinction between cure of disease and reliefof symptoms remains as valid today as in thepast. No patient should leave a medical

consultation feeling that nothing can be doneto help them, even when the disease isincurable.


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Clinical methods - the skills doctors use to

achieve this aim of excellence in clinical

practice - are acquired during a lifetime of

medical work. Indeed, they evolve and change

as new techniques and concepts arise, and as

the doctor develops in experience and

maturity. Clinical methods are acquired by acombination of study and experience, and

there is always something new to learn.


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There are two main steps to making a

diagnosis:

- To establish the clinical features by history and

examination - this represents the clinical

database

- To interpret the clinical database in terms of

disordered function and potential causative

pathologies, whether physical, mental, social,or a combination of these


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BEGINNING THE HISTORY

The process of information gathering may

actually begin by reading any referral

documentation and with the immediate

introduction of doctor and patient. However,

once the social introductions are achieved the

doctor will usually begin with a single opening

question


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A single open-ended question along the lines

of 'Tell me what has led to you coming here

today' gives the patient the chance to begin

with what they feel is most important to

them, and avoids any prejudgement of issues,

or the exclusion of what at first may seem less

important.


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However, at this stage the patient may be very

anxious and nervous, and still making their

own assessment of how they will react to the

doctor as a person. Therefore, a beginning

that focuses on issues that may be more

factual and less emotive can be more

rewarding and lead to a more satisfactoryconsultation.


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NON-VERBAL COMMUNICATION

During any consultation non-verbal

communication is as important as what the

patient says. There may be obvious

contradictions, such as a patient who does not

admit to any worries or anxieties but who

clearly looks as if they have many. Particular

gestures during the description of painsymptoms can give vital clinical clues.


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While concentrating on the conversation with

the patient, the doctor should remain aware

of other clues


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VOCABULARY

It is very important to use vocabulary the

patient will understand and use appropriately.

This understanding needs to be at two levels:

they must understand the basic words used,

and their interpretation of those words must

be understood and clarified by the doctor.


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Words and phrases that need clarification

Ordinary English words

Diarrhoea

Constipation

Indigestion

Being sick

Dizziness Blackouts

Headache

Double vision

Pins and needles Rash

Blister


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Medical terms that may be used

imprecisely by patients

ArthritisSciatica

Migraine

FitsStroke

Palpitation

AnginaHeart attack

Diarrhoea

ConstipationNausea

Piles/haemorrhoids

AnaemiaPleurisy

Eczema

Urticaria

Warts

Cystitis


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INDIRECT AND DIRECT QUESTIONS

Broadly, questions asked by the doctor can be

divided into

indirect or open-ended and

direct or closed.


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Indirect or open-ended questions can be

regarded as an invitation for the patient to

talk about the general area that the doctorindicates is of interest. These questions will

often start with phrases such as

'Tell me more about 'What do you thinkabout, 'How does that make you feel.',

'What happened nex..' or 'Is there anything

else you would like to tell me'.


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They inform the patient that the agenda is very

much with them, that they can talk about

whatever is important, and that the doctor

has not prejudged any issues


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PATIENT-CENTRED

An interview that uses lots of direct questions

is often 'disease-centred', whereas a 'patient-

centred' interview will contain enough open-

ended questions for the patient to talkthrough all their problems, as well as

providing sufficient time. This will help to

avoid the situation in which the doctor andthe patient have different agendas.


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There can often appear to be a conflict if the

patient complains of symptoms that are

probably not medically serious, such as

tension headache, while the doctor is focusingon some potentially serious but relatively

asymptomatic condition such as anaemia or

hypertension.


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In this situation a patient-centred approach

will allow the patient to air all of their

problems, and allow a skilled doctor to

educate the patient as to why the other issuesare also important and must not be ignored


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DIRECT QUESTIONS ABOUT BODILY SYSTEMS

Many disease processes have features that

occur in several bodily systems that at first

may not seem to be related to the patient's

main complaint. For example, a patientpresenting with back pain may have had some

haematuria from the renal cell carcinoma that

has spread and is causing pain


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In addition, during any medical consultation,

however brief, the doctor must be alert to all

aspects of the patient's health and not just the

area or problem with which they havepresented. For example, a general practitioner

would not ignore a high blood pressure

reading in a patient presenting with a rash,even though the two are probably not

connected


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This function of any consultation can be

regarded as 'screening' the patient. Screening

a whole population for a disease is a different

issue, but once the patient has attended adoctor, a simple screening process can be

incorporated into the consultation with little

extra time or effort


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Bodily systems and questions relevant to taking a full history from most

patients. If the specific questions have been covered by the history of the

presenting problem they do not need to be included again. If the answers

are positive then the characteristics of each must be clarified

Cardiorespiratory

Chest pain

Intermittent claudication

Palpitation

Ankle swelling

Orthopnoea

Nocturnal dyspnoea

Shortness of breath

Cough with or without sputum

Haemoptysis


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Gastrointestinal

Abdominal pain

Dyspepsia

Dysphagia

Nausea and/or vomiting

Change in appetite

Weight loss or gain

Bowel pattern and any change

Rectal bleeding

Jaundice


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Genitourinary

Haematuria

Nocturia Frequency

Dysuria

Menstrual irregularity - women Urethral discharge - men


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Locomotor

Joint pain

Change in mobility


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Neurological

Seizures

Collapse or blackouts

Dizziness and loss of balance

Vision

Hearing

Transient loss of function (vision, speech, sight)

Paraesthesiae

Weakness

Wasting

Spasms and involuntary movements

Pain in limbs and back

Headache


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List of clarifications for a complaint of pain

Site

Radiation

Character

Severity

Time course

Aggravating factors

Relieving factors

Associated symptoms


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DRUG HISTORY

At first glance, asking a patient what drugs

they are taking would seem to be one of the

simplest and most reliable parts of taking a

history


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FAMILY HISTORY

Like the drug history, the family history would

seem at first glance to be simple and reliably

quoted.


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OCCUPATIONAL HISTORY

It is always useful to know the patient'soccupation, if they have one, as it is such animportant part of their life and one with whichany illness is bound to interact. In some situationstheir occupation will be directly relevant to thediagnostic process. Other problems, such asasbestos exposure or silicosis, produce effects

many years after exposure, and a carefulchronological occupational history may berequired to elucidate the exposure.


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ALCOHOL HISTORY

The detrimental effects of alcohol on healthcause a variety of problems, and thefrequency of excess alcohol usage in western

countries means that up to 10% of adulthospital inpatients have a problem related toalcohol. To accurately estimate alcoholconsumption and any possible dependency, it

is essential to enquire carefully and not totake what the patient says at face value, but toprobe the history in different ways.

general principles of gastroentorylogy

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