History Taking Skills

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History Taking Skills

  1. 1. History Taking Skills Grzegorz Chodkowski (MD) Riga, Radisson SAS 2009
  2. 2. History Taking Format – Chief complaint – History of present illness (HPI) – Past medical history, which includes • Childhood • Medical • Surgical • OB/GYN • Psychiatric – Family history – Medications – Allergies – Personal/social history – Review of systems
  3. 3. Chief complaint problem / condition that motivated patient to seek care To elicit the chief complaint, ask broad questions: – What brings you in today? – Tell me what has been going on. – What seems to be the problem? – What are your complaints?
  4. 4. History of the present illness (HPI) • Patient's age, sex, occupation • Symptoms (or immediate cause of admission) • Chronology and the seven characteristics of the current symptoms: -Anatomic location -Quality -Quantity or severity -Timing -Setting in which the symptoms occur -Aggravating or relieving factors -Associated symptoms
  5. 5. History of the present illness (HPI) Use facilitating expressions to encourage the patient to continue: – Mmm Hmm. – Yes? – Uh Huh? – And what else? - I am with you – Listening body language
  6. 6. Once the patient has had a chance to tell his or her story you can move on to more directed questions to clarify. • What is wrong? • Where is it wrong? • When did it start going wrong? • How did it go wrong? • Why do you think it is wrong?
  7. 7. Directed or closed questions – Multiple choice • Do you have nausea, vomiting, constipation or diarrhea? • Is the pain sharp, dull or shooting? • Have you had this for days, weeks or months? • How long is the pain: minutes or hours? Important: Pause to wait for each response!!
  8. 8. Yes or No questions • Do you have diarrhea every day? • Do you have any allergies? Quantitive questions • How many loose stools do you have a day?
  9. 9. Remember ! Avoid leading questions – You don’t smoke do you? – You haven’t had any chest pain? – Your wife is your only sexual partner, right? Avoid compound questions – Do you have trouble sleeping? How much sleep do you get? – Do you use cocaine, marijuana or alcohol?
  10. 10. Mnemonics L : Location O : Other symptoms C : Characteristic of the symptom A : Aggravating or alleviating factors T : Timing E : Environment S : Severity
  11. 11. Location • Where does it hurt? • Which part of your chest/head/abdomen is affected? • Does it stay in one place or does it radiate anywhere else?
  12. 12. Other symptoms Pertinent positives and negatives to help you rule in or rule out disease Associated symptoms Other new symptoms that may not be related
  13. 13. Other symptoms - questions • Apart from your chest problem are there any other problems • How’s your appetite? • Do you have any problems with passing water? • Are your bowel motions regular? • Have you noticed any blood in your stools?
  14. 14. Characteristics -quality of the symptom Get the patient to use their own descriptive words if possible. – What does it feel like? – What kind of pain is it? – Can you describe the pain? – Does it affect your sleep/work? – How often are the attacks? – Is the pain continuous or does it come and go?
  15. 15. Aggravating And Alleviating Factors – What makes it better? – What makes it worse? – What has the patient done to try to feel better? – What seems to bring the pain on? – Does anything make it better / worse ? – Is the pain relieved by drugs / rest / changing position? – Have you taken any medicines for the pain? (over the counter medications, friend’s medication)
  16. 16. Timing: Onset & Duration – When did it start? – How long have you had this pain? – When did you first notice it? – Is it intermittent or continuous? – How long does each episode last? – Does the symptom vary with time of day? – Have you ever experienced this before? - Associations with specific events
  17. 17. Environment – What places or events affect the symptom? – Work vs. home – Leisure activities – Diet – Emotions – Heat, dust, altitude
  18. 18. Environment – How is the symptom interfering with the patient’s daily functioning? – If the patient has pain, how bad is the pain on a scale of one to ten?
  19. 19. Patient’s Interview Past Medical History – General state of health – Chronic medical problems – Hospitalizations – Surgical history – History of trauma – Childhood illnesses – Gynecologic history – Health maintenance
  20. 20. Past Medical History • Childhood illnesses • Adult illnesses • Medical conditions • Surgeries • Obstetric/gynecologic • Psychiatric
  21. 21. Past Medical History Eliciting the Past Medical History – How would you describe your health? – Are you having any other problems with your health? – Do you have any other medical problems? – Are you treated for any other medicalconditions? You may learn more about this with medications!
  22. 22. Past Medical History Medical Problems Chronic problems like: • Diabetes mellitus • Hypertension • Chronic back pain • Depression • Coronary artery disease or MI • Congestive heart failure
  23. 23. Past Medical History Medical Problems Hospitalizations – You can’t always accept the patient’s diagnosis, use records to confirm. When? – Are any of these problems active? Where? Why? Childhood Illnesses For how long? – Birth defects, ex., undescended testicle – Attention deficit – Drug use – Anorexia – Athlete – Meningitis – For Pediatrics information about the birth is important
  24. 24. Past Surgical History • What part of the body? • Why? • When? • Where? • Any complications? • Reactions to anesthesia?
  25. 25. Past Surgical History – cont. Trauma Pregnancies What part of the body? • G = Gravida=pregnancies How injured? • P = Para = Live births Where hospitalized? Birth Control Reproductive History – Menstruation • Start • Length and frequency
  26. 26. Medications Health Maintenance Immunizations Screening Tests Medications Medicine name Purpose Dose Route Frequency Side effects Taking as prescribed? Cost issues
  27. 27. Medications - continued Don’t forget! – Over the counter drugs (OCD) – Vitamins – Nutritional supplements – Any borrowed medications
  28. 28. Known allergies and resulting symptoms e.g penicilllin rash Medications - What is the reaction? Other substances, if severe reaction – Ex. Peanut or bee sting allergy
  29. 29. Social History • personal status • occupation • education • home conditions • interests
  30. 30. Family History Major illnesses in the immediate family (parents, grandparents, siblings) Genetic diseases – Sickle cell anaemia, cystic fibrosis Familial diseases – Type 2 diabetes, breast cancer Psychiatric diseases – Heritable – Affect patient’s psychosocial environment Contagious or Toxic – Lead poisoning, influenza
  31. 31. Sample Note Combining Time and Exam • HPI: Mary Smith was seen in my clinic today. She presents with a right breast lump which she noticed 2 weeks ago. The lump is quite firm. She denies weight loss or nipple discharge. ROS: She has noticed some swollen lymph nodes in her neck and axillary regions. Other systems are negative. PMHx: Her only hospitalizations were for the births of her 2 children over 20 years ago. SHx: She does not smoke or drink. FHx: Her mother had breast cancer and a mastectomy. • PE: Mary is healthy appearing. Her eyes clear. Oropharayngeal membranes are pink and moist. Neck has good range of motion with no lymphadenopathy. Heart has a regular rate and rhythm and lungs are clear to auscultation. Abdomen is soft and non-tender. Breast exam revealed normal shape with no skin discoloration. A solid mass was identified in the right breast with some swelling of the axillary lymph nodes. She is alert and oriented x 3 and neurologically grossly intact. • Labs and x-ray: Mammogram reveals a 2 cm mass in the right breast. She also has a small cyst in her left breast but no clear lymph node involvement. • Impression: Otherwise healthy 46-year-old woman with right breast lump and axillary lymph node swelling. Plan: Mary and her husband were at my office for about 45 minutes and I spent 30 minutes talking to them about her prognosis and risks and benefits of surgery. She agrees to breast biopsy with sentinel node biopsy on Tuesday.
  32. 32. Thank You! Any Questions?

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