History taking dr.bilal
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History taking dr.bilal History taking dr.bilal Presentation Transcript

  • Dr.Bilal Natiq Nuaman Lecturer at Ibn-Sina Medical College C.A.B.M. ,F.I.B.M.S. ,D.I.M. ,M.B.Ch.B. 2013-2014 1
  • What is History Taking? • Asking questions of patients to obtain information and aid diagnosis. • Gathering information for the purpose of generating differential diagnoses. 2
  • “Always listen to the patient they might be telling you the diagnosis”. (Sir William Osler 1849 - 1919) 3
  • Key Principles of Patient Assessment • It is estimated that 80% of diagnoses are based on history taking alone. • Use a systematic approach. • Practice infection control techniques. • Establish a rapport with the patient. • Ensure the patient is as comfortable as possible. • Listen to what the patient says.
  • Key Principles of Patient Assessment • Ensure consent has been gained. • Maintain privacy and dignity. • Summarise each stage of the history taking process. • Involve the patient in the history taking process. • Maintain an objective approach. • Ensure that your documentation (of the assessment) is clear, accurate and legible. (Scott 2013, Talley and O’Connor 2010, Jevon 2009) 5
  • Assessment (Consultation) Model • Begining BASICS 1-Setting up : Quiet , private space (curtains) in medical ward . 2-Starting assessment : (make sure you are talking to the correct patient)  Stand on the right side  Greeting – shake hands with smile  Introduce yourself.  Take Permission  Proper Position 6
  • • Active Listening • Be sensitive to your patients privacy and dignity . • Respect for patient • Good Rapport(communications) • Systemic enquiry Disease-oriented systematic enquiry Dealing with patients feelings Empathy : helping your patients feel that you understand what they are going through 7
  • • Information Gathering the exploration of the patient’s problem(s), in order to discover:  Biomedical perspective  Patient’s perspective  Background information 8
  • • Context Understand your patients personal constraints and supports , including where they live ,who they live with , where they work ,who they work with , what they actually do ,their cultural and religious beliefs , and their relationships and past experience . It is about them as a person , it may not be appropriate to explore these sensitive areas with everyone . Establish patients job and explore in some depth what his job entails 9
  • • Sharing information • Achieving a shared understanding: – Relates explanations to the patient. – Encourages the patient to contribute. • Planning, shared decision making: – Shares own thinking as appropriate. – Negotiates a plan. – Checks with the patient about the plan of action. Clarify and summarize Use words that your patients understands and tailor your explanation to your patient , you would use very different terms when dealing with a lawyer as opposed to a farmer . Speak clearly and audibly Do not use jargon Do not use unnecessarily emotive words 10
  • Summary • • • • • • Be systematic in your approach. Establish a rapport with the patient. Listen to what the patient is saying. Clarify and summarise information. Provide a ‘safety net’. Recognise own boundaries and seek senior support. • Escalate and/or refer to the appropriate person. 11
  • Initiating the Session • Preparation • Establish rapport • Identify the reason for the consultation 12
  • Initiating the Session Identifying the reason for the consultation • Open questions: – Always start with an open ended question and take the time to listen to the patient’s ‘story’. • Closed questions: – Once the patient has completed their narrative to closed questions which clarify and focus on aspects can be used. • Leading questions: – Questions based on your own assumptions that lead the patient to the answer you want to hear. These should not be used at all. 13
  • Initiating the Session Identifying the reason for the consultation Open questions: - “How can I help you?” - “You said you have pain on movement, can you tell me which movements makes your pain worse?” Closed questions: - “Are you still taking the aspirin your GP prescribed?” - “Is that an accurate summary of your symptoms?” Leading questions: - “You are not allergic to anything are you?” - “Are your joints painful in cold weather?” 14
  • Start with opening questions and actively listen to patient (few minutes without interruption) Useful opening questions might be : D: What seems to be the problem? D: Could you tell me why you have to come into hospital? 15
  • Establishing rapport Non verbal communications •S •O •L •E •R Sits square on facing the patient Maintains open body position Leans slightly forward Eye contact is maintained Relaxed (in an appropriate posture) (Kaufman 2008) 16
  • Responding to cues • A Cue could be defined as a signpost to an area in the history that you might otherwise ignore but which may be very important to the patient . • Cues are very common . They are often not consciously presented by patients but offer an insight into undeclared concerns . • Does the patient catch his breath , change breathing pattern ,become pale , or flushed , look agitated , shows restless limb or body movements ,become upset , or change eye contact ? All these are recognized signs of stress 17
  • • Examples of Verbal Cues include : P: I hoped it wasn’t anything serious. P: Its my chest again. P: Of course it could just be stress . There are also cues in the pitch , volume , rhythm of speech and there may be cues in censored speechin what is not said . P: Its no better (what's no better) P:Im worried (about what) P:I feel worse (worse than what or when ) 18
  • • Some times , patients use generalizations to express their concerns : P : I don’t like hospitals. P : It never seems to get any better . Cues may be non-verbal . A patient may look sad or anxious and it might be appropriate to respond : D : You look worried about that . Not all cues need an immediate response . Sometimes retuning to it later is effective : D : You mentioned earlier that you hadn't wanted to come into hospital . was there anything worrying you in particular about hospital? 19
  • Initiating the Session Establishing rapport Common Pitfalls of History Taking 1. Providing false reassurance 2. Giving unwanted advice 3. Using authority 4. Using “why” questions 5. Using professional jargon 6. Using leading or biased questions 7. Talking too much 8. Interrupting or changing the subject 9.Writing answers of every questions in a paper front of patient like police investigation 20
  • Initiating the Session • The practitioner’s role combines: – Establishing rapport – Listening – Demonstrating empathy – Facilitating – Clarifying NB: this role is performed throughout the whole history taking and clinical examination process. 21
  • Gathering Information • The practitioner’s role combines: – – – – – – Maintaining rapport Listening Demonstrating empathy Facilitating Clarifying Summarising 22
  • The stages for the interview 1. 2. 3. 4. Establishing rapport Invites the patient’s story Establishing the agenda Generating and testing diagnostic hypotheses 5. Creating a share understanding of the problem 6. Planning and close interview 23
  • Factors in establishing rapport • Introduce yourself in a warm, friendly manner. • Maintain good eye contact. • Listen attentively. • Facilitate verbally and non-verbally. • Touch patients appropriately. • Discuss patients’ personal concerns. 24
  • 2. Invites the patient’s story • Use open-ended questions directed at the major problem(s) • Encourage with silence, nonverbal cues, and verbal cues • Focus by paraphrasing and summarizing 25
  • 3.Establishing the agenda • • • • Use open-ended questions initially Negotiate a list of all issues - avoid detail! Chief complaint(s) and other concerns Specific requests (i.e. medication refills) 26
  • 4.Generating and testing diagnostic hypotheses 27
  • • 5.Creating a share understanding of the problem • Eliciting the patient’s perspective • 6.Planning and close interview 28
  • Skills of interview • • • • • • • Nonverbal Facilitation Reflection Clarification Summarization Validation Empathic responds 29
  • Types of Nonverbal Communication • • • • • Kinesics Paralanguage Vocal interferences Spatial Usage Self-presentation cues 30
  • Kinesics • Eye Contact • Facial expressions • Emoticons • Gesture • Posture • Touch 31
  • Touch • Touching and being touched are essential to a healthy life • Touch can communicate power, empathy, understanding Paralanguage • Pitch • Volume • Rate • Quality • Intonation 32
  • Vocal Interferences • Extraneous sounds or words that interrupt fluent speech – “uh,” “um” – “you know,” “like” • Place markers • Filler 33
  • Self-Presentation Cues Physical Appearance What message do you wish to send with your choice of clothing and personal grooming? 34
  • 1. Introduction and identifying data • Principle complaint 2.Presenting complaint(s) (PC) 3. History of presenting complaint(s) (HPC): • Details of current complaint • SOCRATES or PQRSTA • Effects of complaint on activities of living 4.Systems review 5. Past/Previous medical history (PMH) • Past illnesses, hospitalisations, operations • Past treatments 6. Drug history and Allergies • Prescribed medication • Over the counter medication / herbal remedies • Any side-effects or problems with medication • Any allergies 7. Social history (SH) • Occupation, Marital status, Accommodation, Hobbies, Social life • Smoking and alcohol consumption • Diet, Sleeping, General wellbeing, 8. Family history (FH) 9. Patient’s ideas, concerns and expectations 35
  • Taking history • Identification: Name, age, sex, Date of admission (DOA) , Residence Religion Occupation Marital status 36
  • Chief Complaint & Duration • The main reason push the pt. to seek for visiting a physician or for help • Usually a single symptoms, occasionally more than one complaints eg: chest pain, palpitation, shortness of breath, ankle swelling etc • The patient describe the problem in their own words. • It should be recorded in pt’s own words. • What brings your here? How can I help you? What seems to be the problem? 37
  • Cheif Complaint (CC) • Short/specific in one clear sentence communicating present/major problem/issue. • Timing – fever for last two weeks or since Monday • Recurrent –recurring episode of abdominal pain/cough • Any major disease important with PC e.g. DM, asthma, HT, pregnancy, IHD: • Note: CC should be put in patient language. 38
  • History of Present Illness - Tips • you should begin by inviting patients to provide an account of recent events in their own words. Learn to listen without interruption and encourage the patient to continue the story right up to the time of interview. • When did you last feel fit and well? • When did you first notice a change in your usual state of health? • What was the first symptom you noticed? • When was that and what has happened since? • What else have you noticed about your health? • What has happened to you since you came 39
  • History of Present Illness - Tips • • • • • Elaborate on the chief complaint in detail Ask relevant associated symptoms Have differential diagnosis in mind Lead the conversation and thoughts Decide and weight the importance of minor complaints • In details of present problem with- time of onset/ mode of evolution/ any investigation;treatment &outcome/any associated +’ve or -’ve symptoms. 40
  • Sequential presentation • Always relay story in days before admission e.g. 1 week before the admission, the patient fell while gardening and cut his foot with a stone. • Narrate in details – By that evening, the foot became swollen and patient was unable to walk. Next day patient attended Nuaman hospital and they gave him some oral antibiotics. He doesn’t know the name. There is no effect on his condition and two days prior to admission, the foot continued to swell and started to discharge pus. There is high fever and rigors with nausea and vomiting. 41
  • • In details of symptomatic presentation • If patient has more than one symptom, like chest pain, swollen legs and vomiting, take each symptom individually and follow it through fully mentioning significant negatives as well. E.g the pain was central crushing pain radiating to left jaw while mowing the lawn. It lasted for less than 5 minutes and was relieved by taking rest. No associated symptoms with pain/never had this pain before/no relation with food/he is Known smoker,diabetic & father died of heart attack at age of 45. 42
  • • Avoid medical terminology and make use of a descriptive language that is familiar to them • Describe each symptom in chronological order • The symptoms of related system should be described in history of present illness not on ROS and mentioned even they are negative. 43
  • Pain Site : somatic pain-well localized Visceral pain – more diffuse (angina) Onset : speed of onset and any associations Character : e.g. Sharp, dull, burning, tingling, stabbing,crushing, Radiation (of pain or discomfort) through local extension or referred Alleviating factors Timing Exacerbating factors (Talley and O’Connor 2010) Severity 44
  • Symptom analysis (OPQRSTAN) • Onset of disease • Position/site • Quality, nature, character – burning sharp, stabbing, crushing; also explain depth of pain – superficial or deep. • Relationship to anything or other bodily function/position. • Radiation: where moved to • Relieving or aggravating factors – any activities or position 45
  • • Severity – how it affects daily work/physical activities. Wakes him up at night, cannot sleep/do any work. • Timing – mode of onset (abrupt or gradual), progression (continuous or intermittent – if intermittent ask frequency and nature.) • Treatment received or/and outcome. • Associated symptoms?. • Negative : important 46
  • System Review (SR) • This is a guide not to miss anything • Any significant finding should be moved to HPI or PMH depending upon where you think it belongs. • Do not forget to ask associated symptoms of PC with the System involved • When giving verbal reports, say no significant finding on systems review to show you did it. However when writing up patient notes, you should record the systems review so that the relieving doctors know what system you covered. 47
  • ROS GENERAL • Appetite • Weight • Sleep • Fever • Energy 48
  • Systems Review Central Nervous System / Neurological: • Headaches • Head injury • Dizziness • Vertigo • Sensations • Fits / faints • Weakness • Visual disturbances • Memory and concentration changes Endocrine: Eye: • Visual changes • Redness • Weeping • Itching / irritation • Discharge Cardiovascular: • Excessive thirst • Chest pain • Tiredness • Heat intolerance • Hair distribution • Change in appearance of eyes • Breathlessness • Palpitations • Ankle swelling • Pain in lower legs when walking 49
  • Systems Review Respiratory: • Shortness of breath • Cough • Wheeze • Sputum • Colour of sputum • Blood in sputum • Pain when breathing Ear, Nose and Throat: (often incorporated into the Respiratory System review) • Earache • Hearing deficit • Sore throat Gastrointestinal: • Dental / gum problems • Tongue problems • Difficulty in swallowing • Nausea • Vomiting • Heartburn • Colic • Abdominal pain • Change of bowel habits • Colour of stools (Douglas et al. 2005) 50
  • Systems Review Genitourinary system: • Pain on urination • Blood in urine • Sexually transmitted infections Women: • Onset of menstruation • Last menstrual period • Timing and regularity of periods • Length of periods • Type of flow • Vaginal discharge • Incontinence • Pain during sexual intercourse Men: • Hesitancy passing urine • Frequency of micturition • Incontinence • Urethral discharge • Erectile dysfunction • Change in libido (Douglas et al. 2005) 51
  • Systems Review Musculoskeletal: • Joint pain • Joint stiffness • Mobility • Gait • Falls • Time of day of pain Integumentary (Skin): • General pallor of patient, e.g. pale, flushed, cyanotic, jaundiced • Rashes • Lumps • Itching • Bruising (Douglas et al. 2005) Head to ... ... toe assessment 52
  • Past Medical History • Start by asking the patient if they have any medical problems • IHD/DM/Asthma/HT/TB/Jaundice/Fits :E.g. if diabetic- mention time of diagnosis/current medication/clinic check up • Past surgical/operation history • E.g. time/place/ and what type of operation. Note any blood transfusion and blood grouping. • History of trauma/accidents • E.g. time/place/ and what type of accident 53
  • Drug History • Drug History (DH) • Any allergies to medications and what was the reaction?(penicillin) • Which medications are you currently taking: – The name of the medication – The dosage form – How are they taking it (by which route) – How many times a day – For what reason (if not known or obvious) 54
  • ALLERGIES • Do you have an allergy to or avoid any medications due to side effects? • What type of reaction do you have? PRESCRIPTION MEDICATIONS • What prescription medications do you take on a regular basis? • When do you take them? NON-PRESCRIPTION MEDICATIONS • What non-prescription over-the-counter (OTC) medications do you take on a regular basis? • When do you take them? HERBALS/SUPPLEMENTS/VITAMINS • What herbal, natural or homeopathic remedies do you take? • What vitamins or minerals do you take? • When do you take them? • When do you take them? 55
  • Do you use any: • eye drops • nose sprays • puffer (inhalers) • medicated lotions or creams • medicated patches Do you receive any: • needles (injections) Do you take any medication on a regular basis: • for sleep • for your stomach • for your bowels • for pain 56
  • Treatment abbreviations • bd (Bis die) - Twice daily (usually morning and night) • tds (ter die sumendus)/tid (ter in die) = Three times a day mainly 8 hourly • qds (quarter die sumendus)/qid (quarter in die) = four times daily mainly 6 hourly • Mane/(om – omni mane) = morning • Nocte/(on – omni nocte) = night • ac (ante cibum) = before food • pc (post cibum) = after food • po (per orum/os) = by mouth • stat – statim = immediately as initial dose • Rx (recipe) = treat with 57
  • Family History Age, status (alive, dead) of relatives – medical problems of relatives (ask about cancer, especially breast, colon, and prostate; TB, asthma; MI; HTN; thyroid disease; kidney disease; DM; bleeding disorders) – Write out or use a family tree. – 58
  • 59
  • Social History • patient profile (may include marital status and children, financial support and insurance; education) • Occupation : Current and previous (clarify exactly what a job entails) Exposure to hazards or irritants ,e.g.. chemicals, asbestos , flour dust ..and use mask. Effects of job on patient Attidude of patient to job Hobbies of keep birds --------- psittacosis pneumonia and extrinsic allergic alveolitis . Farmer--------- extrinsic allergic alveolitis .
  • Home circumstances Type of home , owned or rented , rural or urban Water supply , sewage system , animal breading Travel history : (if suspect infectious disease ) Travel-induced : middle ear problems and deep vein thrombosis . Country-related: malaria , hepatitis A , HIV , Typhoid fever , Hemorrhagic fever , Schistosomiasis 61
  • lifestyle risk factors • Smoking history - amount, duration and type. • Drinking history - amount, duration and type. • Exercise history : do you take any regular exercise , how often? Do you use the stairs or lifts ?have you had to reduce exercise because of illness? • Diet history : do you have any dietary restrictions and how have decide on these ? Frequency and times of meals and variety and types of foods eaten. 62
  • Other Relevant History • • • • • • Gyane/Obstetric history if female Immunization if small child Note: Look for the child health card. sexual history if suspected STD or infectious disease Note: If small child, obtain the history from the care giver. Make sure; talk to right care giver. • If some one does not talk to your language, get an interpreter(neutral not family friend or member also familiar with both language). Ask simple & straight question but do not go for yes or no answer. 63
  • Patient’s ideas, concerns and expectations • What have you thought might be causing your symptoms? • Is there anything in particular that concerns you? • What have you been told about your illness? • What do you expect to happen while you are in hospital? • Do you expect any difficulties in coping when you go home? • Do you have any questions you would like me to pass on to the medical or nursing staff? 64
  • FIFE Feelings related to illness (Concerns) Ideas on what is happening to him (Beliefs) Functioning in terms of the impact on daily life Expectations of the illness 65
  • “Medicine is learned at the bedside and not in the classroom”. (Sir William Osler 1849 – 1919) 66