The History Always remember the golden ruleBeing Logic

The History Always remember the golden rule…[Being Logic and Chronologic]

The Sequence of the Interview n Greeting the patient and establishing rapport n Inviting the patient’s story n Establishing the agenda for the interview n Expanding and clarifying while testing hypotheses

The Sequence of the Interview n Creating a shared understanding of the problem n Negotiating a plan for evaluation and treatment n Patient education n Planning for follow-up and closing the interview

The Medical History n n n n Personal History Social History Chief complaint Past Medical History Preliminary Data Medications Allergies Family History of the Present Pregnancy / Illness

The concept of the preliminary data n Do you still remember being logic and chronologic?

The Chief Complaint n This is the main reason that the patient sought help today. n To elicit the chief complaint, ask broad questions: – What brings you in today? – Tell me what has been going on. – Tell me how can I help you?

Chief Complaint… n So far that you are taking the history from a female, Always find an answer to the question: Is she pregnant or NOT? n Chief complaint starts at the point of time when the lady was symptom free

Chief Complaint Example n Doctor: Hello, Mrs. Samara, what brings you in today? n Patient: I am having this problem with my menses. n Doctor: Tell me more about it. n Patient: Its like my menses are starting to come earlier than I expect and are becoming heavier.

Chief Complaint Example, (contd. ) n Doctor: Anything else about the menses? n Patient: Well, they are becoming more and more painful.

Chief Complaint Description n “This is a 27 year old teacher complaining of recent onset of changes in her menses which are becoming more frequent, heavier and associated with more pain. ” n Give me another suggestion….

Chief Complaint n The initial chief complaint may not be the “true” reason that the patient came in. n If you uncover another reason for the patient coming in you can include that in your chief complaint.

Chief complaint n Why does a patient seek care? – Unbearable symptoms – Anxiety about the meaning of the symptoms – They have another problem they are unaware of or embarrassed to reveal – They are in a life crisis.

Past Medical History – General state of health – Chronic medical problems – Hospitalizations – Surgical history – History of trauma – Childhood illnesses – Health maintenance

Past Medical History n 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 medical conditions? • You may learn more about this with medications.

Past Medical History n Medical Problems – Chronic problems like: • • • Diabetes mellitus Hypertension Chronic back pain Depression Coronary artery disease or MI Congestive heart failure

Past Medical History n Medical Problems – You can’t always accept the patient’s diagnosis, use records to confirm – Are any of these problems active?

Past Medical History n Childhood Illnesses – – – – Birth defects, ex. , undescended testicle Attention deficit Drug use Anorexia Athlete Meningitis For Pediatrics information about the birth is important

Past Medical History n Hospitalizations When? Where? Why? For how long?

Past Medical History n Surgical History What part of the body? When? Where? Any complications? Reactions to anesthesia?

Past Medical History n Trauma What part of the body? How injured? Where hospitalized?

Past Medical History n Reproductive History – Menstruation • Start • Length and frequency – Pregnancies • G = Gravida=pregnancies • P = Para = Live births Birth Control

Health Maintenance n Immunizations n Screening Tests

Medications n n n n Medicine name Purpose Dose Route Frequency Side effects Taking as prescribed? Cost issues

Medications n Don’t forget! – Over the counter medications – Vitamins – Nutritional supplements

Allergies n Medications – What is the reaction? n Other substances, if severe reaction – Ex. Peanut or bee sting allergy

Family History n Genetic diseases – Sickle cell anemia, cystic fibrosis n Familial diseases – Type 2 diabetes, breast cancer, what else? n Psychiatric diseases – Heriditary – Affect patient’s psychosocial environment n Contagious or Toxic – Lead poisoning, influenza

Elements of the Patient Profile n Topics – Demographics and Occupation • Age, gender, race, ethnic group, religion, marital status, education, occupation n Typical Screening Questions – Now that I know something about your symptoms, tell me a little about yourself. All I know is that you’re 53 years old and married. – What kind of work do you do? What exactly does that job involve?

Elements of the Patient Profile n n Topics – Lifestyle • Nutrition and diet • Daily activities and exercise • Cigarette, alcohol, and drug use Typical Screening Questions – Tell me a bit about yourself. – What is an average day like for you? – What’s your diet like? Tell me what you eat on an average day. – Do you have time for regular exercise? – Do you smoke cigarettes?

Elements of the Patient Profile n Topics – Relationships • Family and household composition • Support system • Marital and other significant relationships • Sexual history n Typical Screening Questions – Now tell me about your family. You’ve been married how long? Children? – Any stresses or problems with your family? – Any problems in your marriage?

Demographics n Tell me about your background (ethnicity/cultural beliefs) n How far did you get in school? n Do you ever have difficulty reading/understanding labels on medicines or other instructions? n How would you describe your reading ability?

Occupational Survey n Essentials of a Quick Occupational Survey – Do you work outside your home? – What kind of work do you do? – Tell me what that job is like for you. – Is that what you’ve always done? What other jobs have you held in the past?

Occupational Survey n Essentials of a Quick Occupational Survey – Do you now - or did you in the past - have exposure to fumes, chemicals, dust, loud noise, radiation? – Do you think anything at work (or at home) is affecting your symptoms now? How about stress at work? – Do you have any financial stress (it’s certainly very common these days)?

Lifestyle n Do you smoke, how much? Have you ever tried to quit? n How much alcohol do you drink? n Tell me about your diet. What did you eat yesterday? n Are you happy with your current weight? n Do you participate in regular exercise?

Relationships n Become more specific – With whom do you live? – How is your relationship with your son’s father? – What are some good and bad things about your present relationship? – What would you change?

Sexual History n Essential part of most patient’s life experience (even parents and grandparents) n Sexual contact may be the source of illness (HIV, Hepatitis B & C, Human papillomavirus, etc. ) n Depression, anxiety, and anger may relate to underlying sexual problems n Many physical diseases or medications lead to sexual dysfunction

Asking the difficult questions n Be supportive & encouraging – make no assumptions - use term partner – suppress any personal preferences/biases – do not rush the interview and let the patient clarify n Following these suggestions, you will be more likely to get honest answers

Beginning the Sexual History n. A lot of men have sexual problems when they take blood pressure medicine. Have you noticed any problems? n It sounds as though your marriage has been a good one. How about your sexual relationship? n Many girls (boys) your age have questions about sex and birth control. How about you? n Many people these days worry about AIDS. Do you have any concerns about being at risk for AIDS?

Beginning the Sexual History n Do you have any questions or concerns about sexuality or sexual functioning? n Are you having any sexual problems? n Many people who are ill experience a change in their sexual function. Have you noticed any change? n Has your interest in sex changed recently? Since you’ve been ill?

Summary n Be genuine and encouraging n Do not rush n Get to know your patient’s – Demographics and Occupation – Lifestyle – Relationships

Menstrual History n This is the customary menstrual history n Starts with menarche and ends with the LMP n Dates, Dates and Dates

Past Obstetric History n Do you still remember being logic and chronologic n 2 -digit code n 5 -digit code [G-TPAL]

n History of the present Illness Vs n History of the present pregnancy

History of the Present Illness n In the “HPI” you will expand on the patient’s chief complaint. n This is a story of the patient’s problem. n What has happened since they last felt well? n It should contain all the information you need to form a differential diagnosis.

History of the Present Illness, Ex. n Ms. Fawkeya is a 27 year old pregnant housewife with tingling and pain in her right arm. She is in her eighth month of pregnancy and has had an intermittent pain shooting down from her right shoulder to her hand for the last month. She rates it as 8 out of 10 in severity at its worse. The pain is worse at night, sometimes waking her from sleep. It usually lasts for two or three hours.

Ms. Fawkeya (con. ) n The pain improves during the day and sometimes resolves completely. Picking up her 18 month old son makes it worse. Shaking her hand improves it. She also has a numbness in her right thumb, index and middle fingers which is present with the pain and persists for a few hours afterwards. She has no weakness in the hand. She had the same symptoms during her last pregnancy.

History of the Present Illness n Start general and become more specific. n Begin with open-ended questions as you used to get the chief complaint – Tell me more about the pain. – What else is going on? – What was that like for you?

History of the Present Illness n Use facilitating expressions to encourage the patient to continue: – Mmm Hmm. – Yes? – Uh Huh? – And what else? – Listening body language

HPI n 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?

HPI n 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? • Pause to wait for each response.

HPI – Yes or No questions • Do you have diarrhea every day? • Do you have any allergies? – Quantitative questions • How many loose stools do you have a day?

HPI n Avoid leading questions – You don’t smoke do you? – You haven’t had any chest pain? – Your wife is your only sexual partner, right?

HPI n Avoid compound questions – Do you have trouble sleeping? How much sleep do you get? – Do you use cocaine, marijuana or alcohol?

HPI n L: Location n O: Other symptoms n C: Characteristic of the symptom n A: Aggravating or alleviating factors n T: Timing n E: Environment n S: Severity

HPI n Location – Where is the problem? – Does it move or radiate?

HPI n 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

HPI n Characteristics – Quality of the symptom – Get the patient to use their own descriptive words if possible – What does it feel like?

HPI n Aggravating and Alleviating Factors – What makes it better? – What makes it worse? – What has the patient done to try to feel better? • Over the counter medications? • Friend’s medication? • Therapies?

HPI n Timing – When did it start? – 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?

HPI n Environment What places or events affect the symptom? – Work vs. home – Leisure activities – Diet – Emotions – Heat, dust, altitude

HPI n Severity – 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?

HPI To get the LOCATES information move from the general to the specific: A 21 year old second year medical student in excellent health comes in complaining of abdominal pain. Patient: I have this terrible pain in my stomach right here (pointing to the right lower quadrant of her abdomen. ) n Doctor: Tell me more. n

HPI Example n n n Patient: Well, it’s a stabbing pain and it started late last night. It just keeps getting worse and worse. I just can’t get comfortable. Doctor: Is there anything else going on? Patient: I have completely lost my appetite which is very unusual for me. Doctor: Does anything make it better or worse? Patient: It really hurt riding in the car on the way over here, especially going over bumps. I feel best lying curled up in bed.

HPI n n n Doctor: What were you doing when this came on? Patient: I had just come home after eating dinner at my friend’s house. Doctor: When was your last meal? Patient: Dinner. Doctor: When was your last bowel movement? Patient: Yesterday morning.

HPI n Doctor: Have you had any nausea? n Patient: I am kind of nauseated right now. n Doctor: Diarrhea? n Patient: No. n Doctor: Vomiting? n Patient: No.

HPI n Doctor: Have you had a fever or chills? n Patient: Not that I know of. n Doctor: Have you had any pain when you urinate? n Patient: No.

HPI n Doctor: How would you rate your pain on a scale of one to ten if one is no pain at all and ten is the worst pain you ever had? n Patient: Nine. n Doctor: Ok, let me ask you some quick questions about your past medical history.