3 medical history

8/9/2019 3 Medical History

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the medical historythe medical history

herni supraptiherni suprapti


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... the interview is potentially the most... the interview is potentially the mostpowerful, sensitive instrument at thepowerful, sensitive instrument at thecommand of the physician.command of the physician.

Goerge Engel - 1973Goerge Engel - 1973


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the interview such a powerfulthe interview such a powerfulinstrument instrument


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A patient brings to the doctorA patient brings to the doctor

their :their :

pro!lems, usually in the form of symptomspro!lems, usually in the form of symptomsor complaintsor complaints

an"ieties a!out their pro!lemsan"ieties a!out their pro!lems

concerns a!out other aspects of their lifeconcerns a!out other aspects of their life


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#he interview !etween patient and#he interview !etween patient and

doctor is the cornerstone of thedoctor is the cornerstone of thepro!lem-solving process.pro!lem-solving process.


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#he doctor$s role is to gain as#he doctor$s role is to gain asaccurate a picture as possi!le of theaccurate a picture as possi!le of the

patient$s pro!lemspatient$s pro!lems


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%ow is this done %ow is this done

Esta!lish a rapport with the patient usingEsta!lish a rapport with the patient usingthe s&ills outlined in 'hapter (.the s&ills outlined in 'hapter (.

#his will ena!le the patient to tell their#his will ena!le the patient to tell their

story, including their underlying concerns, asstory, including their underlying concerns, ascompletely as possi!le.completely as possi!le.

)se a framewor& for ta&ing a medical)se a framewor& for ta&ing a medical

historyhistory


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%ow is this done %ow is this done

*rocess the information ac+uired, supplemented !y*rocess the information ac+uired, supplemented !ythe results of the e"amination and appropriatethe results of the e"amination and appropriateinvestigations.investigations.

#his stage involves the &nowledge of clinical medicine#his stage involves the &nowledge of clinical medicine

and decision-ma&ing processes that develop withand decision-ma&ing processes that develop withe"periencee"perience

E"plain to the patient what may !e wrong and howE"plain to the patient what may !e wrong and howthey might !e helped.they might !e helped.

#o do this successfully demands good communication#o do this successfully demands good communications&ills and involving the patient in their management.s&ills and involving the patient in their management.


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Beginning an interview :Beginning an interview :

establishing rapportestablishing rapport good way to !egin an interview good way to !egin an interview#he enior egistrar of a medical firm#he enior egistrar of a medical firm

has as&ed one of the students to cler&has as&ed one of the students to cler&/r. 0ones, ust admitted from casualty./r. 0ones, ust admitted from casualty.#he student finds that /r. 0ones is in a#he student finds that /r. 0ones is in aside ward and is reading the newspaperside ward and is reading the newspaperwhen he enters the room.when he enters the room.


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/r 0ones, 2$m sorry to interrupt you !ut/r 0ones, 2$m sorry to interrupt you !ut2$m en rown, one of the students2$m en rown, one of the studentsattached to 4r /orrison$s firm. 2$ve !eenattached to 4r /orrison$s firm. 2$ve !eenas&ed to come and tal& to you a!out theas&ed to come and tal& to you a!out thepro!lem that !rought you into hospital sopro!lem that !rought you into hospital sothat 2 can tell 4r /orrison a!out youthat 2 can tell 4r /orrison a!out youwhen he does his ward round later thiswhen he does his ward round later this

wee&. 2 can spend a!out 56 minuteswee&. 2 can spend a!out 56 minutestal&ing with you. 2s that alright tal&ing with you. 2s that alright

es sure - go ahead.es sure - go ahead.

8ell, 2$d li&e to ta&e some notes so that 28ell, 2$d li&e to ta&e some notes so that 2can write up your history later. %ow docan write up your history later. %ow do

you feel a!out that you feel a!out that #hat$s fine !y me.#hat$s fine !y me.


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Gathering information: takingGathering information: taking

a medical historya medical history $isten to the patient. #hey are giving you the$isten to the patient. #hey are giving you thediagnosis: ;ene aennec6 patientsstudy = >6 patients ?? = the correct diagnosis was made on the patient$s history?? = the correct diagnosis was made on the patient$s history

alonealone

7 = the initial diagnosis changed after the physical7 = the initial diagnosis changed after the physicale"aminatione"amination 7 = it was changed after the results of investigations were7 = it was changed after the results of investigations were

availa!leavaila!le


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@ften you will !e as&ed to $ta&e a history@ften you will !e as&ed to $ta&e a historyfrom the patient$ - an e"pression thatfrom the patient$ - an e"pression thatimplies that the process flows in oneimplies that the process flows in onedirection, from patient to doctordirection, from patient to doctor

ut we have seen that what the doctorut we have seen that what the doctordoes ;e.g. !ody language, manner ofdoes ;e.g. !ody language, manner of+uestioning and listening< influences how+uestioning and listening< influences howpatients divulge their pro!lems.patients divulge their pro!lems.

2t has !een said that doctors should learn2t has !een said that doctors should learnto receive, not to ta&e, a medical history.to receive, not to ta&e, a medical history.

emem!er that you will o!tain a moreemem!er that you will o!tain a moreaccurate and relevant history of theaccurate and relevant history of thepatient$s pro!lems if you develop goodpatient$s pro!lems if you develop goodcommunication s&ills.communication s&ills.


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The structure of a medicalThe structure of a medical

historyhistory8hen you !egin your clinical training you8hen you !egin your clinical training youwill pro!a!ly !e given writtenwill pro!a!ly !e given writteninstructions oninstructions on

$%ow to ta&e a medical history:$%ow to ta&e a medical history:a system for ta&ing a history !ased ona system for ta&ing a history !ased on

this framewor& ;#a!le 3.1


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The structure of a medical historyThe structure of a medical history

asic information a!out the patientasic information a!out the patient4escription of presenting pro!lem4escription of presenting pro!lem

%istory of presenting pro!lem%istory of presenting pro!lemeview of !ody systemseview of !ody systems*ast medical history*ast medical history

Aamily historyAamily historyocial historyocial history


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Basic information about the patientBasic information about the patient

BameBame ddressddress gege @ccupation@ccupation /arital status/arital status

ou should try to find out their name !efore theou should try to find out their name !efore theinterview. ou may prefer to gather the rest of theinterview. ou may prefer to gather the rest of the

information during the interview = this avoids as&ing ainformation during the interview = this avoids as&ing alist of +uestions, which may not !e a good way tolist of +uestions, which may not !e a good way to!egin an interview.!egin an interview.


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description of their presenting problemdescription of their presenting problem

Aind this out !y as&ing an open +uestion =Aind this out !y as&ing an open +uestion =

C'ould you please tell me what pro!lemC'ould you please tell me what pro!lem

!rought you to hospitalC!rought you to hospitalC C8hy have you come to see the doctorC8hy have you come to see the doctor

todayCtodayC

ecord their answer ver!atim in the notes.ecord their answer ver!atim in the notes.


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e"amples from three patientse"amples from three patients

/rs #@B ;a teacher, aged D(, married, with (/rs #@B ;a teacher, aged D(, married, with (children


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ometimes a patient will provide aometimes a patient will provide adiagnosis rather than a symptom= $2diagnosis rather than a symptom= $2

have arthritis in my legs:have arthritis in my legs:

8hen this happens, it is important8hen this happens, it is important

to as& the patient what they areto as& the patient what they aree"periencing= $'ould you tell mee"periencing= $'ould you tell mewhat symptoms you have$what symptoms you have$

#heir understanding of arthritis#heir understanding of arthritismight not !e the same as yours.might not !e the same as yours.


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#he patient may well descri!e not#he patient may well descri!e notonly their pro!lemsonly their pro!lems

!ut also tell you a!out their!ut also tell you a!out their

conditioncondition remem!er that patients can teachremem!er that patients can teach

us a great deal.us a great deal.


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patient may descri!e their complaint in patient may descri!e their complaint inan emotional way=an emotional way=

/ 48E/ 48E 2 felt so awful that 2 thought 2 was going to2 felt so awful that 2 thought 2 was going to

die.die.

4 )'4 )' #hat must have !een very frightening. 4o you#hat must have !een very frightening. 4o you

want to tal& a!out it now or shall we go on andwant to tal& a!out it now or shall we go on andtal& a!out it latertal& a!out it later


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Be"t, as& the patient if they have any otherBe"t, as& the patient if they have any otherpro!lemspro!lems

2t is often easier to identify all their pro!lems2t is often easier to identify all their pro!lems!efore o!taining more information a!out the!efore o!taining more information a!out thepresenting complaint =presenting complaint =

4 2#E4 2#E ou$ve told me that you have had trou!le passingou$ve told me that you have had trou!le passing

water. efore we discuss that further, could youwater. efore we discuss that further, could youtell me if you have any other pro!lemstell me if you have any other pro!lems

/ @8B/ @8B

es, 2$ve !een a !it unsteady on my feetes, 2$ve !een a !it unsteady on my feetrecently and a !it short of !reath when clim!ingrecently and a !it short of !reath when clim!ingstairs, and 2$m worried a!out my wife who hasstairs, and 2$m worried a!out my wife who has

ust had a stro&e.ust had a stro&e.


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2t is important to ac&nowledge and2t is important to ac&nowledge andrespond to these emotions !eforerespond to these emotions !eforecontinuing, even if it is decided to dealcontinuing, even if it is decided to dealwith the issues later on in the interview.with the issues later on in the interview.


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/a&e a list of all the patient$s/a&e a list of all the patient$spro!lems - physical, psychologicalpro!lems - physical, psychological

and social - to !e dealt with in turn.and social - to !e dealt with in turn.#his will help you to structure and#his will help you to structure and

pace the interview.pace the interview.

2t will also decrease the chance of2t will also decrease the chance ofthe patient producing a pro!lemthe patient producing a pro!lem

;often the one that is worrying them;often the one that is worrying themmost< ust as they are a!out to leavemost< ust as they are a!out to leavethe room.the room.


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2n this situation, you should never2n this situation, you should neverignore the pro!lem raised. #heignore the pro!lem raised. #he

strategy you use to deal with it willstrategy you use to deal with it willdepend on a num!er of factors,depend on a num!er of factors,including the time availa!le and howincluding the time availa!le and how

severe you thin& the pro!lem is.severe you thin& the pro!lem is.

ou should give the patient anou should give the patient anopportunity to descri!e the pro!lem.opportunity to descri!e the pro!lem.2f you feel it can !e discussed at2f you feel it can !e discussed at

another time, you might say,another time, you might say,:*erhaps we can deal with that when:*erhaps we can deal with that when

you come to see me again tomorrowF.you come to see me again tomorrowF.


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@f course, the patient may have@f course, the patient may have

pro!lems that they have forgottenpro!lems that they have forgottenor may !e reluctant to divulge at theor may !e reluctant to divulge at thestart of the interview.start of the interview.

ut as you proceed and !uild up aut as you proceed and !uild up arapport, the patient may well feelrapport, the patient may well feel

a!le to discuss their pro!lems witha!le to discuss their pro!lems withyou.you.


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history of their presenting problemhistory of their presenting problem

#his is one of the most important parts of the#his is one of the most important parts of thehistoryhistory

our aims should !e to =our aims should !e to =

o!tain a detailed history that is complete,o!tain a detailed history that is complete,accurate and relevantsaccurate and relevants find out the patient$s perception of what isfind out the patient$s perception of what is

wrongwrong

esta!lish their attitudes to the pro!lemesta!lish their attitudes to the pro!lem

determine what effect the pro!lem has ondetermine what effect the pro!lem has ontheir day-to-day life and relationships.their day-to-day life and relationships.


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8%# =8%# = 8hat does it feel li&e 8hat !rings it on 8hat does it feel li&e 8hat !rings it on

8%EE=8%EE= how me where it is.how me where it is.%@8 =%@8 = %ow !ad is it %ow is it altered !y food,%ow !ad is it %ow is it altered !y food,

e"ertion, etc. e"ertion, etc.

8%EB =8%EB = 8hen did it start 8hen does it occur ;%ow8hen did it start 8hen does it occur ;%ow

often %ow long for


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timing : when ?timing : when ?

ou will need to &nowou will need to &now when the pain !eganwhen the pain !egan how it startedhow it started its durationits duration how often it occurshow often it occurs how it endedhow it ended

ometimes it is helpful to as& the patient to recall the onset of theometimes it is helpful to as& the patient to recall the onset of thepro!lem and descri!e how it has developed since then. 2f theypro!lem and descri!e how it has developed since then. 2f they

have had numerous different episodes, as& them to descri!e ahave had numerous different episodes, as& them to descri!e atypical one.typical one.


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as& a!out the duration of painas& a!out the duration of pain

4 )'4 )' -- /r 48E/r 48E %ow long does the pain last %ow long does the pain last 0ust a short while.0ust a short while. minute Aive minutes %alf an hour minute Aive minutes %alf an hour @h, not half an hour.@h, not half an hour. %ow long then %ow long then !out fifteen minutes.!out fifteen minutes.


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location : where ?location : where ?

#his is particularly important when the#his is particularly important when thepatient complains of painpatient complains of pain

2t is a good idea to as& them to point to2t is a good idea to as& them to point tothe site, e.g. if it is a!dominal pain, youthe site, e.g. if it is a!dominal pain, youneed to &now the e"act position in orderneed to &now the e"act position in orderto ma&e the diagnosis.to ma&e the diagnosis.


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radiation : where ?radiation : where ?

2t is also necessary to find out if the pain2t is also necessary to find out if the painradiates and, if so, where the pain spreads toradiates and, if so, where the pain spreads to

person with gall !ladder disease may person with gall !ladder disease may

e"perience pain in the upper a!domen and ine"perience pain in the upper a!domen and inthe right shoulderthe right shoulder

omeone with a slipped disc may have !ac&omeone with a slipped disc may have !ac&pain that spreads down their leg.pain that spreads down their leg.


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quality : what is it like ?quality : what is it like ?

ymptoms vary in +ualityymptoms vary in +uality *ain may !e descri!ed as sharp, dull, tight, thro!!ing,*ain may !e descri!ed as sharp, dull, tight, thro!!ing,

constant or $comes and goes:constant or $comes and goes: #he type of pain is important in differential diagnosis#he type of pain is important in differential diagnosis patient with pleurisy will usually complain of chest patient with pleurisy will usually complain of chest

pain that is sharp when !reathing inpain that is sharp when !reathing in omeone who has had a heart attac& will usuallyomeone who has had a heart attac& will usually

complain of constant $tight, gripping pain$ in thecomplain of constant $tight, gripping pain$ in the

chestchest


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Associated signs and symptoms :Associated signs and symptoms :what else ?what else ?

s&ing a!out these can provide essential informations&ing a!out these can provide essential informationfor the diagnosis and management of the patient$sfor the diagnosis and management of the patient$scondition =condition =

4 )'4 )' -- /r 48E/r 48E

8hen you had your chest pain, did you have any other8hen you had your chest pain, did you have any othersymptoms at the timesymptoms at the time

es, my heart was racing and 2 felt a !it short ofes, my heart was racing and 2 felt a !it short of

!reath.!reath.

#his part of the history !ecomes easier as your#his part of the history !ecomes easier as your&nowledge of clinical medicine increases.&nowledge of clinical medicine increases.


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Setting: when does it occur ?Setting: when does it occur ?

2t is important to esta!lish the conte"t in which the symptoms2t is important to esta!lish the conte"t in which the symptomsdevelop =develop =

4 @4 @ ou have told me a lot a!out your a!dominal pain and the wayou have told me a lot a!out your a!dominal pain and the way

it$s associated with wind and pro!lems in passing your motions.it$s associated with wind and pro!lems in passing your motions.'ould you tell me now a!out what you are usually doing when the'ould you tell me now a!out what you are usually doing when thepain comes on.pain comes on.

/ #@B/ #@B 2$ve !een thin&ing a!out that. 2 never get this pro!lem when2$ve !een thin&ing a!out that. 2 never get this pro!lem when

2$m on holiday - it seems to happen mostly when 2$m !usy at2$m on holiday - it seems to happen mostly when 2$m !usy atwor&, or when we$re e"pecting visitors at home.wor&, or when we$re e"pecting visitors at home.


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odifying factors :odifying factors :how is it affected by !!! ?how is it affected by !!! ?

Aind out what ma&es the symptoms worse and what ma&es themAind out what ma&es the symptoms worse and what ma&es them!etter =!etter =

4 @ 4 @ / #@B/ #@B

8hen you have the pain, is there anything that ma&es it !etter8hen you have the pain, is there anything that ma&es it !etter 2t$s !etter when 2$ve passed wind or had my !owels open.2t$s !etter when 2$ve passed wind or had my !owels open. %ow does what you eat affect it%ow does what you eat affect it 2 used to eat lots of vegeta!les and fruit, !ut 2$ve cut that2 used to eat lots of vegeta!les and fruit, !ut 2$ve cut that

down and the pain seems to !e a !it !etter.down and the pain seems to !e a !it !etter.

4o you ever ta&e any medicines for the pain4o you ever ta&e any medicines for the pain Bo. 2 tried paracetamol once, !ut that didn$t seem to ma&e anyBo. 2 tried paracetamol once, !ut that didn$t seem to ma&e anydifference.difference.


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#he !est way to o!tain a history of#he !est way to o!tain a history ofthe presenting complaint is to startthe presenting complaint is to start

with an open +uestion, note whichwith an open +uestion, note whichaspects of the pro!lem the patientaspects of the pro!lem the patientdescri!es spontaneously, and thendescri!es spontaneously, and then

fill in the gaps with closed orfill in the gaps with closed orpro!ing +uestions.pro!ing +uestions.ou may find this difficult to doou may find this difficult to do

initially, !ut it is a s&ill that comesinitially, !ut it is a s&ill that comeswith practice.with practice.


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"hat effect on the patient#s"hat effect on the patient#squality of life ?quality of life ?

ou may have found out a lot a!out the impact of theou may have found out a lot a!out the impact of thepro!lem on the patient$s life from their answers topro!lem on the patient$s life from their answers to

your previous +uestions.your previous +uestions.

ou should loo& specifically at the effect on their =ou should loo& specifically at the effect on their = moodmood relationships, particularly with spouse and closerelationships, particularly with spouse and close

familyfamily o!o! leisure and social lifeleisure and social life se"ual activity.se"ual activity.


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4 @ 4 @ / #@B/ #@B

2$m wondering what effect your symptom have had on your2$m wondering what effect your symptom have had on yourlife in general.life in general.

2$m not sure what you$re getting at - !ut 2 &now that2$m not sure what you$re getting at - !ut 2 &now thatthey$ve made me feel a !it low at timesthey$ve made me feel a !it low at times

!it low 'an you e"plain what you mean !y that !it low 'an you e"plain what you mean !y that 8ell, 2 feel a !it fed up when the pain comes ust !efore8ell, 2 feel a !it fed up when the pain comes ust !efore

we$re going out and 2 have to sit on the toilet for ages andwe$re going out and 2 have to sit on the toilet for ages andthen we$re late - myhus!and gets really cross.then we$re late - myhus!and gets really cross.

4oes that worry you *erhaps you could tell me how you4oes that worry you *erhaps you could tell me how youare getting on with your hus!and are getting on with your hus!and

8e$ve had our ups and downs - !ut not too !ad, really.8e$ve had our ups and downs - !ut not too !ad, really. nd what a!out the rest of the family nd what a!out the rest of the family @h, my daughters are fine - we get on really well.@h, my daughters are fine - we get on really well.

Bote how 4 @ uses open +uestions, as&s her to clarifyBote how 4 @ uses open +uestions, as&s her to clarifywhat she means !y $a !it low$, and pic&s up the ver!al cueswhat she means !y $a !it low$, and pic&s up the ver!al cuesa!out her relationship with her hus!and.a!out her relationship with her hus!and.


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"hat is the patient#s understanding of"hat is the patient#s understanding oftheir problem ?their problem ?

#ry to e"plore what the pro!lem means#ry to e"plore what the pro!lem meansfor the patient - what they thin& itfor the patient - what they thin& itmight !e caused !y, or related to =might !e caused !y, or related to =

C*erhaps you could tell me what youC*erhaps you could tell me what youthin& is causing your pro!lemCthin& is causing your pro!lemC

C8hat concerns you most a!out yourC8hat concerns you most a!out your

pro!lemCpro!lemC


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review of body systemsreview of body systems

#his section of the interview involves a series of#his section of the interview involves a series of+uestions related to each of the !ody systems+uestions related to each of the !ody systems

#he purpose is to elicit important symptoms that the#he purpose is to elicit important symptoms that thepatient may have forgotten or may not havepatient may have forgotten or may not have

considered significant !ecause they were not relatedconsidered significant !ecause they were not relatedto their presenting complaint.to their presenting complaint.

tudents often have a pro!lem initially with thistudents often have a pro!lem initially with thissection of the interview = firstly, !ecause ofsection of the interview = firstly, !ecause ofdifficulty in remem!ering all the +uestions to !edifficulty in remem!ering all the +uestions to !eas&edH and secondly, !ecause they are afraid that theas&edH and secondly, !ecause they are afraid that thepatient, who is li&ely to give negative answers to thepatient, who is li&ely to give negative answers to themaority of +uestions, may wonder a!out themaority of +uestions, may wonder a!out the+uestions$ relevance.+uestions$ relevance.


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#he way to overcome these pro!lems#he way to overcome these pro!lemsis to =is to =

)se an aide memories = write down the !ody)se an aide memories = write down the !odysystems or a small card and refer to it in thesystems or a small card and refer to it in theinterview.interview.

2ntroduce this section of the interview !y2ntroduce this section of the interview !ysaying something li&e= $2$m now going to as&saying something li&e= $2$m now going to as&you a series of +uestions a!out commonyou a series of +uestions a!out commonmedical pro!lems. #his is to ma&e sure wemedical pro!lems. #his is to ma&e sure we

don$t miss anything that may !e important$.don$t miss anything that may !e important$.


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#he list of topics to !e covered is#he list of topics to !e covered isshown in Aigure 3.5.shown in Aigure 3.5.

E"amples of +uestions you might as&E"amples of +uestions you might as&include =include =


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'ardiovascular ='ardiovascular =

'ould you tell me if you have any trou!le'ould you tell me if you have any trou!lewith your heart with your heart

8hat a!out chest pain or palpitations 8hat a!out chest pain or palpitations 4o your an&les ever swell 4o your an&les ever swell


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Genito-urinary =Genito-urinary =

4o you ever have any pro!lems passing4o you ever have any pro!lems passingwater water

8hat a!out pain when you pass it 8hat a!out pain when you pass it 4oes it have an unusual colour or smell 4oes it have an unusual colour or smell


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Assessment of the patient#sAssessment of the patient#smental statemental state

#his should form part of the interview with every#his should form part of the interview with everypatient.patient.

y carrying out a !rief assessment of a patient$s mentaly carrying out a !rief assessment of a patient$s mentalstate, you can identify cognitive pro!lems ;which maystate, you can identify cognitive pro!lems ;which mayalert you to the unrelia!ility of their history< and thealert you to the unrelia!ility of their history< and thepossi!ility of a psychiatric disorder.possi!ility of a psychiatric disorder.

!rief account suita!le for routine use will !e given !rief account suita!le for routine use will !e givenhere.here.

/ore detailed descriptions of assessment that should/ore detailed descriptions of assessment that should

!e followed if a psychiatric disorder is suspected are!e followed if a psychiatric disorder is suspected aregiven in te"t!oo&s of psychiatry.given in te"t!oo&s of psychiatry.


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Appearance and behaviourAppearance and behaviour

Bon-ver!al cues are particularly important in theBon-ver!al cues are particularly important in theassessment of a patient$s mental state.assessment of a patient$s mental state.

#a&e particular notice of dress and general#a&e particular notice of dress and generalappearance.appearance.

*atients who are demented or who are alcohol-*atients who are demented or who are alcohol-dependent often neglect their appearanceH thedependent often neglect their appearanceH thedepressed patient may arrive dressed in som!erdepressed patient may arrive dressed in som!ercolours.colours.

4uring the interview, ta&e note of the eye contact4uring the interview, ta&e note of the eye contact

that the patient ma&es with youH the depressedthat the patient ma&es with youH the depressedpatient may !e reluctant to loo& you in the eye.patient may !e reluctant to loo& you in the eye.

lso note their general !ehaviour= are they restless,lso note their general !ehaviour= are they restless,retarded, etc.retarded, etc.


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speechspeech

ou may have noticed a!normalities during theou may have noticed a!normalities during theinterviewH it is important to note them as theyinterviewH it is important to note them as theyare indicators of psychological andare indicators of psychological andneurological functioning.neurological functioning.

Bote !oth the +uantity and +uality of theBote !oth the +uantity and +uality of thepatient$s speech.patient$s speech.

#he patient who is depressed may spea& in a#he patient who is depressed may spea& in a

slow flat toneH the e"cita!le, manic patientslow flat toneH the e"cita!le, manic patientmay have a rapid, pressuriIed way of spea&ing.may have a rapid, pressuriIed way of spea&ing.


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oodood

4uring the interview, you will have gathered4uring the interview, you will have gatheredinformation a!out mood or affect from the patient$sinformation a!out mood or affect from the patient$s!ehaviour and manner of e"pression.!ehaviour and manner of e"pression.

4o they seem depressed, an"ious, agitated, manic or4o they seem depressed, an"ious, agitated, manic orwithdrawn withdrawn #o e"plore this further, you can as& general +uestions#o e"plore this further, you can as& general +uestions

such as =such as = C2$m wondering if you still enoy life as much as you usedC2$m wondering if you still enoy life as much as you used

toCtoC C%ow have you reacted to the pro!lems you$ve hadCC%ow have you reacted to the pro!lems you$ve hadC C*erhaps you can tell me if you$ve felt a !it down ;stressed,C*erhaps you can tell me if you$ve felt a !it down ;stressed,

an"ious, e"cited< recently. Can"ious, e"cited< recently. C


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Thought contentThought content

Patients have delusions or ideas aboutPatients have delusions or ideas about

suicidesuicide

Question :Question : 'Could you tell me what's on your mind at'Could you tell me what's on your mind at

present?'present?'

"You seem to have been having a lot of"You seem to have been having a lot of

problems. wonder if you sometimes thin!problems. wonder if you sometimes thin!that life is not worth living?"that life is not worth living?"


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Cognitive functionCognitive function

Patient's orientation and general mentalPatient's orientation and general mentalfunctioningfunctioning

Question :Question :

''d li!e to as! you some uestions about your thin!ing''d li!e to as! you some uestions about your thin!ingand memory. Could you tell me today's date andand memory. Could you tell me today's date andwhere you are now?'where you are now?'

#ests of cognitive function include short$term#ests of cognitive function include short$termmemory testsmemory tests ''m going to tell you the names of three ob%ects and ''m going to tell you the names of three ob%ects and

want you to remember them. #he ob%ects are fish&want you to remember them. #he ob%ects are fish&stars& house'.stars& house'.


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Past medical historyPast medical history

nformation about the patient's previous illnessesnformation about the patient's previous illnesses

is important for an understanding of theiris important for an understanding of their

presenting illness and their managementpresenting illness and their management

previous general healthprevious general health previous illnessesprevious illnesses

admissions to hospitaladmissions to hospital

operationsoperations accidents and in%uriesaccidents and in%uries

pregnanciespregnancies


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( ()**( ()** You've told me a lot about the problems you've hadYou've told me a lot about the problems you've had

with your bowels& and 've as!ed you a number ofwith your bowels& and 've as!ed you a number of

uestions. +ow 'd li!e to as! you about any illnessesuestions. +ow 'd li!e to as! you about any illnessesyou've had in the past. Could you tell me aboutyou've had in the past. Could you tell me aboutthese?these?

,(* -#)+,(* -#)+

et me thin!& had my appendi/ out when was 01 oret me thin!& had my appendi/ out when was 01 or02 and had a chest infection when 0 was on holiday02 and had a chest infection when 0 was on holidayin the 3*- 1 years ago. #hat4s allin the 3*- 1 years ago. #hat4s all

( ()**( ()**

5ave you had any other operations ?5ave you had any other operations ? ,(* -#)+,(* -#)+ +o& haven't.+o& haven't.


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( ()**( ()**-nd have you been in hospital at any other-nd have you been in hospital at any other

time?time?

,(* -#)+,(* -#)+)nly when had the two children $ they're)nly when had the two children $ they're

grown up nowgrown up now( ()**( ()**-nd did you have any problems with your-nd did you have any problems with your

pregnancies ?pregnancies ?

,(* -#)+,(* -#)++o $ never felt better6+o $ never felt better6


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( ()**( ()** Could you tell me if you've had any accidents or in%ured yourselfCould you tell me if you've had any accidents or in%ured yourself

at any time ?at any time ?

,(* -#)+,(* -#)+ 7ell& yes. slipped on the ice and bro!e my leg about 08 years7ell& yes. slipped on the ice and bro!e my leg about 08 years

ago. -ctually was in hospital then for several wee!s $ 'dago. -ctually was in hospital then for several wee!s $ 'dforgotten thatforgotten that

( ()**( ()** id they operate ?id they operate ? ,(* -#)+,(* -#)+

Yes& they did because they said it was a nasty brea!Yes& they did because they said it was a nasty brea!

( ()**( ()** )9 $ so %ust to summarise what you've told me : you had your)9 $ so %ust to summarise what you've told me : you had your

appendi/ out when you were young and& more recently& youappendi/ out when you were young and& more recently& youbro!e your leg and had a chest infection& but recovered well onbro!e your leg and had a chest infection& but recovered well oneach occasioneach occasion


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#here are a number of specific conditions#here are a number of specific conditions

that you may want to e/clude from thethat you may want to e/clude from thepatient's past medical history at this stage.patient's past medical history at this stage.

#hese will depend on circumstances but#hese will depend on circumstances but

may include tuberculosis& rheumatic fevermay include tuberculosis& rheumatic fever

and diabetes.and diabetes.


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Family historyFamily history

#his is important for two reasons#his is important for two reasons

irst& the patient may be suffering from airst& the patient may be suffering from a

genetically determined disease.genetically determined disease.

*econd& their concerns about their*econd& their concerns about their

presenting problems may be related to thepresenting problems may be related to the

e/perience of other members of the family.e/perience of other members of the family.


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e/amplee/ample

,rs -lton may be worried about her bowel,rs -lton may be worried about her bowel

symptoms because her father died fromsymptoms because her father died from

cancer of the colon.cancer of the colon.

#his is an important piece of information#his is an important piece of informationpartly because it will help you to interpret howpartly because it will help you to interpret how

she presents her symptoms& andshe presents her symptoms& and

also because she has an increased ris! ofalso because she has an increased ris! of

developing cancer of the colon& which is& atdeveloping cancer of the colon& which is& atleast in part& genetically determined.least in part& genetically determined.


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7hen ta!ing a family history as! about all7hen ta!ing a family history as! about all

first$degree relativesfirst$degree relativesParentsParents

*iblings*iblings

ChildrenChildren if they are livingif they are living

if not& the cause of death :if not& the cause of death :


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( ()**( ()**

'm sorry to hear that your father died of'm sorry to hear that your father died ofcancer. 5ow old was he when he died ?cancer. 5ow old was he when he died ?

,(* -#)+,(* -#)+

5e was 12& thin!5e was 12& thin!( ()**( ()**-nd your mother ?-nd your mother ?

,(* -#)+,(* -#)+)h& she's well& apart from a bit of arthritis $)h& she's well& apart from a bit of arthritis $

she's ;8.she's ;8.


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#a!ing a family history must be done sensitively.#a!ing a family history must be done sensitively.

Patients will realise the importance of it if youPatients will realise the importance of it if you

e/plain the possible significance of thee/plain the possible significance of the

information.information.

a family history of specific diseasesa family history of specific diseases heart diseaseheart disease

high blood pressurehigh blood pressure

diabetesdiabetes

You may wish to draw a medical family tree .


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Social historySocial history

build up a picture of the patient as abuild up a picture of the patient as a

person outside of the hospital orperson outside of the hospital or

consulting room :consulting room :

5ow do they spend an average day ?5ow do they spend an average day ?7hat is the structure of their family and how7hat is the structure of their family and how

do the members relate to each other ?do the members relate to each other ?

7hat is their lifestyle ?7hat is their lifestyle ?o they have any worries about finance&o they have any worries about finance&

accommodation& etc.?accommodation& etc.?


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Social historySocial history

interpret the way in which a patientinterpret the way in which a patient

presents their problemspresents their problems

discuss the management of their problemsdiscuss the management of their problems

#he social history divided into#he social history divided into the patient profilethe patient profile

lifestyle lifestyle

sources of both stress and supportsources of both stress and support


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Patient profilePatient profile

information aboutinformation about family lifefamily life

other close relationshipsother close relationships

wor! and daily activitieswor! and daily activities *uitable opening uestions would be :*uitable opening uestions would be : "Could you tell me something about yourself as a"Could you tell me something about yourself as a

person? Perhaps you could start with your family andperson? Perhaps you could start with your family and

other people you are close to."other people you are close to." "Could you tell me what you do in an average day?""Could you tell me what you do in an average day?"


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Occupational historyOccupational history

is important because it may be ofis important because it may be of

aetiological significanceaetiological significancee.g. hand dermatitis in people using stronge.g. hand dermatitis in people using strong

detergentsdetergentsbac! pain in nursesbac! pain in nurses

it may influence the ability to return to wor!it may influence the ability to return to wor!

e.g. a nurse with bac! pain may be unable toe.g. a nurse with bac! pain may be unable toreturn to her %ob in a geriatric wardreturn to her %ob in a geriatric ward


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Occupational historyOccupational history

#he essential features of an occupational#he essential features of an occupational

history are :history are :current %ob all previous %obs .all previous %obs .


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LifestyleLifestyle

#he patient's smo!ing and drin!ing habits#he patient's smo!ing and drin!ing habits

are particularly important because theyare particularly important because they

are ris! factors for a number of diseasesare ris! factors for a number of diseases


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Smoking historySmoking history

o you smo!e?o you smo!e?

7hat do you smo!e?7hat do you smo!e?

5ow much do you smo!e?5ow much do you smo!e?

5ow long have you smo!ed li!e this?5ow long have you smo!ed li!e this?

f the patient is a non$smo!er& as! if theyf the patient is a non$smo!er& as! if they

have smo!ed in the past and if so& for howhave smo!ed in the past and if so& for howlong?long?


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Drinking historyDrinking history

f the patient drin!s& as!f the patient drin!s& as!what they drin!what they drin!

how much during an average wee!how much during an average wee!


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( @3C9( @3C9 'd li!e to as! you now about your drin!ing habits. Can you tell me if you'd li!e to as! you now about your drin!ing habits. Can you tell me if you

drin! alcohol?drin! alcohol? ,( -7A*,( -7A*

Yes& but not much. suppose you'd call it social drin!ing.Yes& but not much. suppose you'd call it social drin!ing. ( @3C9( @3C9

Could you tell me what you drin!?Could you tell me what you drin!? ,( -7A*,( -7A*

,ostly beer: go down to the pub most nights to have a few pints with,ostly beer: go down to the pub most nights to have a few pints with

my mates.my mates. ( @3C9( @3C9

- few pints? t would help me if you could go over the past wee! and- few pints? t would help me if you could go over the past wee! andgive me an idea of how much you dran! each evening?give me an idea of how much you dran! each evening?

,( -7A*,( -7A* 7ell& let me see $ 'went down to the pub perhaps four times last wee!7ell& let me see $ 'went down to the pub perhaps four times last wee!

and dran! about three pints each evening.and dran! about three pints each evening. ( @3C9( @3C9

#han! you& that's very helpful.#han! you& that's very helpful.


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Drug historyDrug history

all current drugs prescribed by a doctorall current drugs prescribed by a doctor

all drugs that the patient has bought overall drugs that the patient has bought over

the counterthe counter

if they misuse drugsif they misuse drugs


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Sources of stressSources of stress

5ealth can be severely affected by stress5ealth can be severely affected by stress

related to wor!& personal relationships&related to wor!& personal relationships&

finances& accommodation& etc.finances& accommodation& etc.

uestions :uestions :"Could you tell me if you feel particularly"Could you tell me if you feel particularly

stressed?"stressed?""7hat sort of things cause you stress?""7hat sort of things cause you stress?"


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closing an interviewclosing an interview

summarise what you have been toldsummarise what you have been told

as! if the patient has any corrections& oras! if the patient has any corrections& or

additional informationadditional information

than! them for tal!ing to you.than! them for tal!ing to you.


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Can the patient have access toCan the patient have access to


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Can the patient have access toCan the patient have access to

their notestheir notes #he answer is generally 'YesB#he answer is generally 'YesB patients have the right of access to the information that apatients have the right of access to the information that a

hospital or general practice holds about themhospital or general practice holds about them t applies to all paper and electronically held recordst applies to all paper and electronically held records

n e/ceptional circumstances access may be denied& forn e/ceptional circumstances access may be denied& fore/ample when it is considered that a patient may bee/ample when it is considered that a patient may beharmed by seeing their notesharmed by seeing their notes

t follows that you should never write anything that yout follows that you should never write anything that you

would not wish the patient to seewould not wish the patient to see

n the future patients may be sent copies of the lettersn the future patients may be sent copies of the letterswritten about them and evidence shows that the ma%oritywritten about them and evidence shows that the ma%oritywould welcome this.would welcome this.

Some practical hints for taking aSome practical hints for taking a


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Some practical hints for taking aSome practical hints for taking a

historyhistory#a!e every opportunity you are given to#a!e every opportunity you are given to

interview patientsinterview patientsYou will develop the s!ills only throughYou will develop the s!ills only through

repeated practicerepeated practice@e prepared to spend time with patients $@e prepared to spend time with patients $

this is necessary in order to learn how tothis is necessary in order to learn how to

ta!e an accurate& systematic history.ta!e an accurate& systematic history.You will speed up as you become moreYou will speed up as you become moree/perienced.e/perienced.

obtain a good history if you use theobtain a good history if you use the


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obtain a good history if you use theobtain a good history if you use the

s!ills outlined in Chapter :s!ills outlined in Chapter :establish rapportestablish rapport

listen activelylisten actively

as! mainly open uestionsas! mainly open uestions

pic! up and respond to verbal and non$pic! up and respond to verbal and non$

verbal cuesverbal cues

facilitate or help if the patient gets stuc!facilitate or help if the patient gets stuc!summarise and chec! for accuracysummarise and chec! for accuracy

,a!e an aide memoire of the history ta!ing,a!e an aide memoire of the history$ta!ing


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,a!e an aide memoire of the history$ta!ing,a!e an aide memoire of the history$ta!ing

seuece.seuece.

,ost people need to ta!e notes as they are,ost people need to ta!e notes as they areinterviewing.interviewing.

You may decide to ma!e rough notes and toYou may decide to ma!e rough notes and to

write them up later.write them up later.

(emember to e/plain why you are ta!ing notes(emember to e/plain why you are ta!ing notes

and if it is acceptable.and if it is acceptable.

-lways maintain intermittent eye contact& and-lways maintain intermittent eye contact& and

don't give the impression that your notes aredon't give the impression that your notes aremore important than what the patient is sayingmore important than what the patient is saying

Presenting a patient at a !ardPresenting a patient at a !ard


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Presenting a patient at a !ardPresenting a patient at a !ard

roundroundPresenting a patient at a case conferencePresenting a patient at a case conference

or ward round is an integral part ofor ward round is an integral part oftraditional medical educationtraditional medical education

-t first& all students are li!ely to find this a-t first& all students are li!ely to find this adaunting e/perience that may provo!edaunting e/perience that may provo!ean/iety.an/iety.

5owever& even if practise does not ensure5owever& even if practise does not ensureperfection& it should increase yourperfection& it should increase yourconfidence and competence .confidence and competence .

"uidelines for presenting a"uidelines for presenting a


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"uidelines for presenting a"uidelines for presenting a

patient on a !ard roundpatient on a !ard round

PreparationPreparation

PresentationPresentation

Follo! upFollo! up


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P t tiP t ti


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PresentationPresentation

(ela/(ela/

*pea! clearly and fluently*pea! clearly and fluently

@e concise@e concise

@e accurate@e accurate f you are as!ed uestions and !now the answer&f you are as!ed uestions and !now the answer&

e/press it confidentlyD if you are unsure or do note/press it confidentlyD if you are unsure or do not

!now& it is probably best to say so!now& it is probably best to say so @e sensitive to the needs of the patient if they@e sensitive to the needs of the patient if they

are presentare present

F llF ll


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Follo! upFollo! up

f possible& go bac! to see your patientf possible& go bac! to see your patient

after the round to discuss and concernsafter the round to discuss and concerns

they may have arising from what theythey may have arising from what they

heardheard(eflect on your presentation.(eflect on your presentation.

7hat did you do well?7hat did you do well?

7hat could you have improved?7hat could you have improved?

-s! for feedbac! from your peers-s! for feedbac! from your peers

the purposes of presenting patientsthe purposes of presenting patients


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the purposes of presenting patientsthe purposes of presenting patients

at ward rounds or conferences :at ward rounds or conferences : )n ward rounds particularly& the consultant and other)n ward rounds particularly& the consultant and other

medical and nursing staff can learn about the patient'smedical and nursing staff can learn about the patient'shistory and the findings of the physical e/amination andhistory and the findings of the physical e/amination andinvestigation. -s a student& you are li!ely to have had theinvestigation. -s a student& you are li!ely to have had thetime to get to !now your patient well& to have obtained atime to get to !now your patient well& to have obtained ahistory& and to have carried out a physical e/amination.history& and to have carried out a physical e/amination.

#he presentation of a patient will stimulate discussion on#he presentation of a patient will stimulate discussion ondiagnosis and management.diagnosis and management.

t is an important learning opportunity for students.t is an important learning opportunity for students.

Presenting information to others is a crucial s!ill to bePresenting information to others is a crucial s!ill to beacuired in training and something you will have to doacuired in training and something you will have to dothroughout your professional life.throughout your professional life.

Common concerns a#outCommon concerns a#out


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Common concerns a#outCommon concerns a#out

intervie!ing patientsintervie!ing patientsThe patient refuses to see meThe patient refuses to see me

$ forget !hat %uestion to ask ne&t$ forget !hat %uestion to ask ne&t

The patient asks me a %uestion a#outThe patient asks me a %uestion a#out

their conditiontheir condition

The patient tells me something inThe patient tells me something in

confidenceconfidence

The patient starts crying or #ecomesThe patient starts crying or #ecomes

emotionalemotional

Th ti t f tThe patient ref ses to see me


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The patient refuses to see meThe patient refuses to see me

#his rarely happens. #he ma%ority of#his rarely happens. #he ma%ority ofpatients are happy to see students andpatients are happy to see students and

often benefit from the time and supportoften benefit from the time and support

you may be able to give them. *ometimes&you may be able to give them. *ometimes&however& a patient may have told theirhowever& a patient may have told their

story to several students and does notstory to several students and does not

want to do it again. on't ta!e refusal towant to do it again. on't ta!e refusal tosee you as a personal affront.see you as a personal affront.

$ forget !hat %uestion to ask$ forget !hat %uestion to ask


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$ forget !hat %uestion to ask$ forget !hat %uestion to ask

ne&tne&t interviewing a patient involves more thaninterviewing a patient involves more than

as!ing uestionsas!ing uestions

it is natural to feel an/ious when there areit is natural to feel an/ious when there are

gaps in the conversation& but silences aregaps in the conversation& but silences areimportant.important.

if you lose the thread of the interview& youif you lose the thread of the interview& you

might carry on by summariing what themight carry on by summariing what thepatient has told you so far.patient has told you so far.

The patient asks me a %uestionThe patient asks me a %uestion


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The patient asks me a %uestionThe patient asks me a %uestion

a#out their conditiona#out their condition-s a general rule& you should not answer-s a general rule& you should not answer

uestions that patients may as! you about theiruestions that patients may as! you about their

condition but suggest that they as! their doctor.condition but suggest that they as! their doctor.

Clearly& you will have to use your ownClearly& you will have to use your own%udgement. f the patient as!s you a simple%udgement. f the patient as!s you a simple

factual uestion and you are confident of thefactual uestion and you are confident of the

answer& you might reply& but never be afraid toanswer& you might reply& but never be afraid to

say& ' don't !now& but 'll as! r Peters tosay& ' don't !now& but 'll as! r Peters todiscuss this with you'& or& ' don't !now. 'll go anddiscuss this with you'& or& ' don't !now. 'll go and

loo! it up'.loo! it up'.



96/101


confidenceconfidence Confidentiality of information is an essential partConfidentiality of information is an essential part

of the patient$doctor relationship and has beenof the patient$doctor relationship and has beenenshrined in professional codes of practice sinceenshrined in professional codes of practice since5ippocrates.5ippocrates.

Patients may feel that it is easier to tal! to youPatients may feel that it is easier to tal! to youas a student& particularly as you may be able toas a student& particularly as you may be able tospend more time with them than the rest of thespend more time with them than the rest of thestaffstaff

)ccasionally& a patient may give you information)ccasionally& a patient may give you informationthat they as! you to !eep confidential. #his putsthat they as! you to !eep confidential. #his putsyou in a difficult position& particularly if theyou in a difficult position& particularly if theinformation is pertinent to their management.information is pertinent to their management.



97/101


confidenceconfidence*ome general guidelines are :*ome general guidelines are : )nly in very e/ceptional circumstances should a doctor)nly in very e/ceptional circumstances should a doctor

brea! a patient's confidence when the patient has notbrea! a patient's confidence when the patient has notgiven consent for information to be divulged.given consent for information to be divulged.

+ever as a student promise a patient confidentiality.+ever as a student promise a patient confidentiality. A/plore why they feel they can't discuss it with a memberA/plore why they feel they can't discuss it with a member

of the medical team. #his may help them to realise theyof the medical team. #his may help them to realise theyshould tell the doctor if it is relevant to their condition andshould tell the doctor if it is relevant to their condition andtreatment.treatment.

f in doubt& discuss your predicament with a seniorf in doubt& discuss your predicament with a seniormember of staff $ without divulging the information givenmember of staff $ without divulging the information givenyou.you.

The patient starts crying orThe patient starts crying or


98/101


#ecomes emotional#ecomes emotional it is natural to feel an/ious andit is natural to feel an/ious and

embarrassed when a patient brea!s downembarrassed when a patient brea!s down

in tearsin tears

try to control your an/iety & avoid

rushing in with uestions and give therushing in with uestions and give the

patient an opportunity to e/press emotion.patient an opportunity to e/press emotion.



99/101

The patient starts crying ore pat e t sta ts c y g o

#ecomes emotional#ecomes emotionalyou can help them do this throughyou can help them do this through

empathy& perhaps by touching their hand&empathy& perhaps by touching their hand&

or using reflective comments :or using reflective comments :

" understand that this must be very upsetting" understand that this must be very upsettingfor you. "for you. "

" can understand why you are so upset."" can understand why you are so upset."

"Perhaps you would li!e to tell me more about"Perhaps you would li!e to tell me more abouthow you feel. "how you feel. "

ey pointsey points


100/101

ey pointsey points

t is important to obtain a complete and accurate history: for thet is important to obtain a complete and accurate history: for thema%ority of patients& a diagnosis can be made on the history alone.ma%ority of patients& a diagnosis can be made on the history alone.

evelop and practise a systematic approach to ta!ing a history: $evelop and practise a systematic approach to ta!ing a history: $introduction and e/planation of tas!introduction and e/planation of tas! personal detailspersonal details presenting problempresenting problem history of presenting problemhistory of presenting problem review of body systemsreview of body systems past medical historypast medical history family historyfamily history social historysocial history summarise and conclude interviewsummarise and conclude interview

Eood communication s!ills are essential. 3se open uestions& listenEood communication s!ills are essential. 3se open uestions& listencarefully& and pic! up and respond to verbal and non$verbal cues.carefully& and pic! up and respond to verbal and non$verbal cues.


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3 medical history

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