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 sessionsof 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 IdentificationPatients ConcernHistory of Present IllnessPast Medical HistoryFamily HistorySocial HistoryReview of SystemsSummaryProblem ListPlan

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 painWhere 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 Doe36 y.o. man from Pakse farmer

Patient Concern: Cough & HemoptysisHistory of Present Illness:

2 month history of cough Sputum contains streaks of bloodCough is worse with smokingNothing improves the coughPatient tried antibiotics with no reliefAssociated symptoms: weight loss of 10 Kg, night sweats, anorexia, fatigue, no chest pain

Past Medical HistoryMedical: no past medical problemsSurgery: no past surgeryAllergies: noneMedications: Took 10 days of cephalexin, no relief

Family History:Mother finished TB Rx 2 months agoFather alive and wellOther family members healthy

Social History: Smokes about 8 cigarettes per day & has smoked for 16 yearsDrinks Beer Lao 1 or 2 per day, Lao Lao at weddingsMarried, 3 children

Review of SystemsOccasional 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 problemExplain that you are going to ask more questions about their medical problems in the past, family medical problems and about their life in generalExplain 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!