The Patient Interview

Presented By:

Joseph S. Ferezy, D.C.

Principles Of The Patient Interview

Difficult to LearnTechniques Continually SharpenedYears of Clinical ExperienceConsideration From a Primarily Chiropractic/neurological Viewpoint

Use Of History Questionnaires

Practice Management Groups Recommend

May Be Good for the Student Doctor

Overlooks Specific Questions Parkinson's

Difficulty Getting in and Out of Chairs Making Rapid Turns Cutting Food Changes in Handwriting

Conversely, Forms May Also Cause the Doctor to Waste Time and Even Diminish the Patient's Confidence by Leading the Doctor to Ask Useless and Even Stupid Questions

Questions Designed to Detect One Illness May Be Completely Irrelevant in Another

The Consummate History Elicitor Must Makethe Patient Completely Comfortable

Impotence

Bladder Incontinence

Fit Into the Patient's Preconception of How a Doctor Should Look and Behave.

Clean, Pressed, White Clinic Jacket and a Tie

A Gold Ring Through the Nose

Minimally, Rigid Standards for Personal and General Office Hygiene Would Be Established.

A Good HistoryAtmosphere Is Unhurried

Patient Allowed Sufficient Time to Answer All of the Questions Completely

"The Patient Interrogation.”

Do Not Allow Rambling Endlessly About Useless Details

Doctor's Social Skills

Too Much History May Be As Bad As Too Little

Clouding the Issue

Wasting Time

Patients May Not Be Good Historians

Imparters

Extractees

Initial Meeting

Biographical Data - Office Questionnaire

Full Name, Date of Birth, Sex, Race, Occupation,Marital Status, Home Address, and Social SecurityNumber Should Be Recorded

Some of This Information Is Important in Diagnostic Considerations

Age

Sex

Race

Occupation

There Is No Replacement for the Attending Doctor When It Comes to History Taking.

Much Information May Be Gleaned by Observation of the Posture of the Patient

Antalgia

Supporting Weight With Upper Extremities

Sitting on the Edge of the Chair

Leaning Backward (Tripod)

Sitting Cross-legged

Observation of Patient Behavior and Shakingthe Patient's Hand May Yield Invaluable In-Formation Regarding Personality, Central and Peripheral Motor Function, Coordination, and Autonomic Function.

A Firm Handshake Is Associated With Confidence and Personability; A Weak or Flaccid Handshake May Indicate Introversion, or Motor Impairment. Inaccuracy Reaching to the Doctor's Hand May Indicate Dysmetria and Be a Sign of Cerebellar Dysfunction.

A Cold, Blue, and Clammy Hand May Indicate Increased Sympathetic Tone, Whereas a Hot, Flushed, and Dry Hand Might Indicate Sympathetic Paralysis. Adductionof the Thumb Into the Palm May Be an Early Sign of Upper Motor Neuron Involvement or a Late Sign of Extrapyramidal Disease.

Radial Nerve Damage Causes Weakness of the Wrist Extensors. Ulnar Nerve Involvement May Cause a Loss of Hypo-thenar and Intrinsic Hand Muscle Mass, Later, a Flexion Contracture of the 4 and 5 Digits, Which May Result in the "Claw Hand” Deformity.

Median Nerve Involvement Causes Thenar Atrophy and a Characteristic "Ape Hand” Deformity.

A Contracture in the Palm Causing Flexion of One or More Fingers May Be a Sign of Dupuytren's Contracture, and Pain in the Area of the Radial Styloid That Is Exaggerated by Volar Flexion Might Indicate De Quervain"s Disease(Stenosing Tenosynovitis of the Abductor Longusand Extensor Brevis).

Patient HistoryPatient Sequestered 16-year-old Female With Headaches Mother or Father Oral Contraceptives Malingerer May Require Coaching

Friend or Relative in the Room May Be Extremely Useful or Absolutely Essential. A Patient With Impaired Communicative Skills or a Very Young Child Is an Example.

A Parent or Spouse May Be Quite Put off by an Office Policy That Completely Excludes His or Her Presence. I Recommend That Interested Friends and Family Be Allowed, Not Invited, Into the History-taking Area but Asked to Wait Outside During the Formal Examination. This Affords the Doctor Ample Opportunity to Add a Private History Session With the

Patient.

Subsequent to the Exam, or During a Report of the Findings Procedure, Any Person Who May Be Able to Contribute to the History's Accuracy Should Be Invited Into the Room.

A Good Patient History

Answer the Who, What, When, Where, and How ofan Illness Who Is This Person? What Exactly Is His or Her Complaint? When Did It First Occur? Where Exactly Is It Located? How Did It Occur?

Specific Areas

Chief Complaint

Present Illness

Past History

Family History

Occupational History

Review of Systems

Chief Complaint

First Sentence of History - Why

Include All Patient's Complaints

Simple and Brief

Always in the Patient's Own Words

The Chief Complaint Is Nothing More Than a List of Related Symptoms Experienced by the Patient Prior to Seeing a Doctor. Failure to Actually Understand a Patient's Complaints Can and Does Often Lead to Many an Erroneous Diagnosis.

History of Present Illness

Single Most Important Portion of a New Patient Work-upEssential Factual Recreation of Events Leading up to Patient's PresentationChronological Sequencing Date and Mode of Onset Location and Character Course and Duration Exacerbate or Alleviate Relation to Other Body Systems

Specific Location

Patient Actually Attempt to Point With One Finger to the Exact Location of the Complaint Radicular Versus Plexus Versus Peripheral Nerve Distributions

Pain in Scleratome Distribution Is "Achey," Deep, and Poorly Localized.

When the Pain Begins in One Location and Radiates to Another, As Is Commonly Encountered in Spinal Complaints, It Is Useful to Have the Patient Actually Point Out the Entire Pathway.

Date and Mode of Onset

Date of Onset Calendar Date Important in Determining the System Involved

Ultimate Diagnosis - Sternal Pain Experienced During Exertion Is More Indicative of Cardiac Disease Than Is Sternal Pain Associated With a Punch in the Chest!

Character"Dizziness”?Pain Should Be Graded and DescribedExact Nature of the Symptoms“Numbness”? Temporal (Time) Profile Progressive Intermittent or Relapsing Acute Onset Followed by Gradual Recovery

Course, Duration, and Effects of Treatment

Improvement or Worsening of a Condition Clearer Understanding of the Entire Situation ofthe Particular Patient

Details of Factors That Alter the Course of the Disease Better After a Night's Sleep? Does Lifting at Work Exacerbate? Does Aspirin or Hot Baths Relieve?

Request Records

Not to Replace Your DiagnosisAvoid Repeating Unnecessary TestsSee If the Patient Has Reported a Similar History in the PastNever Assume a Previous Diagnosis Is Correct

Relationship to Other Symptoms

Patients Are Allowed to Suffer From More ThanOne Illness

Seemingly Unrelated Symptoms Might Dramatically Change the Diagnostic or Therapeutic Options Available Radiation of Pain Lower Extremity Bowel or Bladder Symptoms.

Pre-existing Illness

May Have Direct Bearing Patient May Not See the Relationship

Carpal Tunnel Syndrome Secondary to Hypothyroidism

Back Pain Associated With Genitourinary Disease

Headache Secondary to Hypertension

Past History

Dates and Descriptions of Prior Major Illnesses or HospitalizationsRecent Visits to PhysiciansCurrent Medications or Known AllergiesExercise and Personal HygieneTobacco, Alcohol, or Street Drugs? If So, How Much?

Family History

Grandparents

Mother Migraines

Father

Spouse

Siblings Brother Died From MI

Children

Occupational History

Often OverlookedMay Be Directly or Indirectly Related to the Presenting Complaint Wrist Pain in the Factory Pieceworker or Typist

Chronic Headaches in the Interior Room Painter or High-powered Executive

Uncover Job Specifics

"Warehouse Worker” May Be Lifting Heavy Objects May Be Driving a Forklift

Helps Determine the Cause of the Complaint

Impose Intelligent Job Restrictions

Review of SystemsMay Well Reveal a Symptom or Disease That the Patient Has Omitted From the HistoryApparently Unrelated Symptoms Have a Common Cause Weight Gain May Be Related to Carpal Tunnel Syndrome Hypothyroidism

Back Pain and Incontinence Visual Complaints and Numbness

Areas to ReviewBody WeightSkin and Skin AppendagesEyes, Ears, Nose, and ThroatCardiorespiratory SystemGastrointestinal SystemGenitourinary SystemReproductive System (Including Menstrual and Obstetrical History)Psychiatric State

Do Not Put Words in the Patient's Mouth. The Patient Should Tell the Story, Withthe Doctor Serving As a Guide

There Is No Shortcut to the Development of a Good History. It Is a Painstaking Process That, When Properly Performed, Will Usually Reduce the Diagnostic Possibilities From a List of Dozens to a List of but One or Two.

The History Is Not a Time-consuming Procedure but As a Time-saving Procedure.

Recording The Patient History

It Is Most Beneficial for the Doctor to Learn or Invent a System of Shorthand So That the History Can Be Recorded As It Is Delivered by the Patient

This Enables a Detailed Account to Be Given in theRecord, or to Be Dictated for Transcription at a Later Date

Many Common Medical Terms Have Standardized Abbreviations.

See Appendix AIn the Ferezy Text