2 History taking.pptx99999999999999999999999999999

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1. Clinical History Taking

2. Aims Be able to: Understand the importance of the medical history Identify the relevant processes involved in taking a medical history Recognise the importance of structure in a systematic approach to history taking Understand the importance of ‘red flags’ Be able to take a systematic, comprehensive history from a patient

3. Why? “Without a good history it is an inevitable fact that the patient’s problem will remain undiagnosed, despite examination findings and the results of investigations that follow” (Fishman & Fishman 2005)

4. History Taking …is arguably the most important aspect of patient assessment, and is increasingly being undertaken by health professionals other than doctors ( Crumbie 2006)

5. The Importance of History Taking! 80% of diagnoses in general medical clinics are based on the interview (Epstein et al 2003) 76% correct diagnosis after taking a clinical history only (Peterson et al 1992) 83 % of doctors made correct diagnosis on the basis of medical history only (Hampton et al 1975)

6. What is the purpose of the ‘medical interview?’ To identify ‘problems’. To explore the health/illness of the patient To plan for the next step...

7. History Taking History Taking - Assets Being empathic Being attentive Being articulate Being friendly but business like Being interested

8. The Beginning! Environment! Introduce yourself Ask permission to take the history Have you got the correct person!! Patients Demographics Name Age Occupation Background

9. Structure There is no evidence to support any particular structure in taking a history. However the following can be utilised -

10. General Principles Let the patient tell their story Listen Develop a rapport, be friendly Be interested Use e ye contact Use appropriate language and terms

11. History taking THE PATIENT IS THE MOST IMPORTANT PERSON IN THE ROOM! ‘Always listen to the patient, they might be telling you the diagnosis’ Sir William Osler

12. Set the Agenda Use open-ended questions initially Negotiate a list of all issues - avoid detail! Presenting complaint(s) and other concerns Specific requests (i.e. medication refills) Clarify the patient's ideas, concerns expectations (ICE) "Why now?"

13. History Taking Allow the patient time to tell the story in their own words. If you don’t understand something imply the problem is yours! If you are unsure about the main problem – “If I could make just one thing better what would it be?”

14. History Taking Pitfalls The patient does not always know what is and what is not relevant Hence the importance of a systematic enquiry The patient has an almost universal tendency to describe his/her symptoms not directly but in terms of what he/she thinks they are due to e.g. Neuritis, Rheumatism What do you mean by?

15. History Taking Examples of techniques Open enquiries e.g. Tell me about your pain? How did you react to the tragedy? Closed inquiries When did your pain begin?

16. Structure P resenting Complaint H istory of Presenting Complaint P ast medical history D rugs (medications/allergies) F amily history S ystem enquiry S ocial history Polly (Peter) Has Pretty Damn Fine Sexy (smelly) Stockings (socks)

17. History Taking Open questions Clarification Reflection - involves putting back to the patient a symptom or remark Summary - an expansion on reflection

18. History Taking Key points What to ask and how to ask it Open ended questions are better than closed questions in establishing framework of the history Closed questions provide detail and sharpen the account Keep the history flowing Minimum of interuptions Use reflection and summary when appropriate Use the patient’s own words Avoid technical terms

19. Developing A Structure

20. OLDCART O nset L ocation (Site and radiation) D uration (Fluctuating) C haracter A ggravating R elieving features T reatment Associated symptoms Previous episodes

21. SOCRATES S ite O nset (gradual/sudden) C haracter R adiation A ssociations (other symptoms) T iming/duration E xacerbating/relieving factors S everity (pain score)

22. Past Medical History Open questions What illnesses have you had? (include psychiatric conditions if appropriate)

23. Past Medical History when? any? what? previous Vaccinations Screening Medicals alcohol smoking

24. History Taking Drug History Not just prescribed drugs - include over the counter remedies and alternative medicine Name each substance, dose and duration Compliance Drug allergies & sensitivities

25. Medication and Allergies Medication name if possible Dose Route of administration Recent change Include OTC and homeopathic / herbal Recreational drugs Allergies & Sensitivities When? Diagnosed? How presented, symptoms

26. History Taking Family history Open question - ‘tell me about any illness( es ) which run in the family Ask specifically about immediate family including parents Diagnosis and age Cause of death

27. Social History Family situation Relationships incl. Marital status Occupation Past and present Exposure Community Involvement & Network Hobbies

28. Social History Alcohol history Quantity and type Place of drinking Alone or accompanied Money spent Purpose

29. Social History Tobacco Duration Type - pipe, cigarettes, cigars Amount If stopped when

30. Systematic Inquiry General Well being Appetite Sleep Energy Weight change

31. Systemic Enquiry Direct questioning Organise symptoms by system Explore any positives with open ended questions and then clarify as per presenting complaint Use lay terms Summarise Anything else?

32. Systemic Enquiry C.V.S. Chest pain Breathlessness On exertion Lying flat Wake up at night Orthopnoea Palpitations Ankle swelling Exercise Tolerance Pain in legs when walking

33. Systemic Enquiry R.S. Shortness of breath Chest pain On inspiration Cough Sputum Blood Wheeze

34. Systemic Enquiry GI System Dental / Gum Problems Reduced appetite/weight loss Swallowing painful difficult Indigestion, heartburn Abdominal pain Vomiting Altered bowel habit Blood loss

35. Systemic Enquiry Urogenital Pain on passing urine Frequency - day, night Colour of urine Males: (age), difficulty starting, poor stream, dribbling, discharge, libido Females: menarche, menopause, frequency, regularity, urge or stress, incontinence, discharge, abnormal bleeding, libido

36. Systemic Enquiry CNS Weakness Disturbance of sensation Headaches Visual disturbance Dizziness, blackouts (clarify these) Fits Confusion Disturbance of speech Hearing

37. Systemic Enquiry Locomotor Joint Pain Joint Stiffness Swelling Mobility Gait Falls Redness and warmth

38. Systemic Enquiry The Skin Rash Spots Itching Ulcers Lumps/growths

39. Summary Salient features of Presenting history Relevant past history Background Differential diagnosis

40. History Taking Explanation Most important from the patients point of view Communication skills are vital Speak clearly and audibly Avoid jargon Avoid emotive words Most important information first

41. Questions?