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General Principles of History - Taking

Lecture 1

MB;BS

Year 1 (20112012)

Dr. P Y Lee
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History - Taking

Objectives:By the end of this session you should be able to:

# 1. understand the principles of taking

a medical history

# 2. recall the basic features of the Calgary- Cambridge framework

# 3. be aware of the potential for history

taking to be challenging

# 4. understand and appreciate the importance ofan accurate medical history

# 5. appreciate the importance of effective communication

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History - Taking

What is history-taking? Why must you take a medical history?

Why is history-taking important?

How is history-taking conducted?

What are the different approaches?

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What is HistoryTaking (cont)?

Patient to tell his story

And the doctor to record it.

an art and a science takes patience and experience

time to master

guidelines to follow

An important first step

an accurate history is a must. represents one of the

core clinical skills

and it indications

yourclinical competence

Influences the precision the diagnosis investigations

impacts on treatment

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Importance Of Medical History

Directly reflects the quality of your work

indicates your degree of discipline, exactness andthoroughness at bedside

In the out-patient department

80% of diagnosis

based on historyTaking accurate medical histories

main responsibility in early years

medical history read by others

Estimated that in your

professional life 200,000 consultations

time invested pays dividends

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Basic Principles in History Taking

Principal aims are:

what is wrong with the patient today? In what ways will these problems impact on his life?

following standard approach - history before physicalexamination

understanding that the process of history taking

an active skill not simply passive listening

by paying attention to presenting complaint(s)

explore the details

you should reach a differential diagnosis (a list ofpossible conditions)

failing which means a struggle to find signs on physicalexamination

to confirm your suspicions

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How to take a good History ?

Success of a consultation requires: clinical knowledge

interviewing technique

positive doctorpatient relationship

patient to feel sufficiently at ease

good communication skills a systematic approach a traditional standard approach

to gather all relevant information

# a structural approach to follow

# not meant to be a rigid checklist

# to remain flexible within a format

# adapt to suit your preferences and

the situation

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Also considered aspart of problem solving process

Basic rules to follow:

1. respect

2. professionalism

3. to be a good listener

4. patient-the central figure

5. during consultation6. use your clinical knowledge

7. for the benefit of your patient

Briefly - Medical History

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History - Taking

Basically, there are five parts to a history.

The Calgary-Cambridge scheme.

initiatingthe session gathering information

physical examination

explanation and planning closing the session

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CalgaryCambridge Scheme

Calgary-Cambridge framework:# 1. Initiating the session

introduction and identification

establishing initial rapport

identifying the presenting problem(s)

# 2. Gathering information exploration of problem(s)

understanding the patients perspective

providing structure to the consultation

building the relationship developing rapport

involving the patient

# 3. Physical Examination

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Calgary-Cambridge framework (cont)

# 4. Explanation and Planning providing the correct type and amount of information

aiding accurate recall and understanding

achieving a shared understanding

through incorporating the patients perspective

planning through shared decision making

# 5. Closing the session

** 5 main stages in a consultation within a framework that

provides structure and with emphasis on theimportance of building rapport with the patient.

{In history-taking we deal only with the first two stages}.

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Don'ts of History Taking

Do not interrupt thepatient

Do not use medical

terminology

Do not ask ambiguous orirrelevant questions

Do not use leading

questions in the first

instance

Do not be abrupt

Do not rush the

patient

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Right to Refuse

Right to refuse: You should let the patientsknow that they are free not to answerany of

the questions you ask and that they are free

to terminate the interview at any time.

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Confidentiality & Informed Consent

Confidentiality and informedconsent:

interview is confidential

not absolute

efforts made to protect theidentity and dignity of the subject

special situations when this is notrespected e.g.

reviewed by faculty

small group discussion disclosed when thegeneral

public is put at risk

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Symptoms and Signs

Effective clerking must be systematicallylearned and practiced.

Symptoms and signs:

used synonymously till relatively recently

a distinction made - 19th century, symptomsmean (subjective) complaints

by the patient

signs indicate the (objective)

findings of the physicianWith each symptom, the details are obtained

with OLDCARTS

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Symptoms and Signs (cont)

From the symptoms and signs you are trying toextract answers to five fundamentalquestions.

1. From which organ(s) do the symptoms

arise ?

2. What is the likely cause?3. Are there any predisposing or risk

factors?

4. Are there any complications?

5. What are the patients ideas,

concerns and expectations?

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Structure of a Medical History

Basic information aboutthepatient

1. Presenting Complaint

2. History of PresentingComplaint

3. Past Medical andSurgical history

4. Medication history

5. Allergy

6. Family history7. Social history

8. Systems review

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Beginning an InterviewHow do you begin?Ask yourself what is the **first**

objective you wish to achieve?

to establisha good workingrelationship - rapport

How do you hope to achieve that?

demonstrate your respect, interest

and concern

so

greet your patient and introduce

yourself,

then

state your position in the team explain the purpose of visit

explain what the physician wants

you to do

Ask permission to proceed.

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How to Begin? (cont)

The rule of thumb:

types of questions: open questions

closed questions

clarifying or probing questions

common approach: appropriate choice of questions

# tell me what has brought you to the hospital today

ask open questions (they are less focused) tell me about your headaches

what concerns you most about your headaches

This allows the patient to tell his story (history)before your own prejudices take over.

Encourage him by gentle steering and coaxing.

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How to Begin? (cont)

Closed questions are necessary at the right

time and place. ask closed questions:

Is the headache present when you wake up?

does the headache affect your eyesight?

Closed questions are necessary to obtain andto confirmfacts.

ask clarifying questions: what do you mean by that?

why do you say that?

tell me the details of the last episode of headache

you hadThe key issue is to get a right balance of

questions.

All three types have a place.

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Basic Information about the Patient

For generations there has been

little change in the method

of recording information

from the history.

Background information of

the patient essential.

Name and Age

Address

Date of birth

Ethnic group and religion

Occupation

Marital status

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Presenting compliant / Chief

complaint the main reason the patient

has come for consultation

the next step is to explore

for details keep in mind the Donts inthe process

to elicit the history, beginwith open questions

Why have you come tosee the doctor today? ideally, use the words of the

patient

Example: History of Presenting Complaint

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Example: Presenting or Chief Complaint (cont)

Example:

Doctor: Hello, MrAhmad, what brings youin today?

Patient: I am having thispain over my chest.

Doctor: Tell me moreabout it.

Patient: The pain is overtheleft side of my chest.It came onsuddenly

while I was watchingfootball last night.

History of presenting

complaint

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Example: Presenting or Chief Complaint (cont)

Record the words thatthe patient actuallyused.

do not substitute

no abbreviations

examples: patientrarely complains ofdypsnoea, but will sayshort of breath

Mr. Lee is a 56-year-old mechaniccomplaining ofshortness of breath

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History of Presenting Complaint

Once the chief complaint is

established. Then expandon it.

apply OLD CARTS to obtain

a detailed history that is

complete, accurate andrelevant diagnosis

the history should include:

perception of what is wrong

attitudes to the problem

effect the problem has on the

patient (day-to-day life and

relationship)

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There are several broad questions

which are applicable to any complaintOLD CARTS

Onset

Location

Duration

Character *Aggravating factors

*Alleviating factors

*Associated symptoms

Radiation

Timing

Severity

Explore in detail the circumstancessurrounding the episode or event.


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Application of OLD CARTS in History Taking of Presenting

Complaint

OLD CARTS

Chief complaint -- Pain (stomach pain)

Onset speed of onset

speed of onset (seconds, minutes, hours, days)

Acute (circulatory - thrombosis, embolism) ,( myocardial infarction)

(mechanical intussusceptions,

strangulations)

(traumatic , poisoning) chronic (degenerative, endocrine, tumors)

sub-acute ( as in viral infections, abscess )

try to obtain exact time(s) and date(s) ??

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Complaint (cont)

Location: (site)

somatic pain often well localised (sprained ankle) visceral pain is usually more diffuse (angina)

Duration: how long did the pain last?

Character: ( the nature of pain )

sharp, dull, burning, tingling, stabbing, crushing,tugging, boring descriptive using adjectives

Aggravating and Alleviating factors: anything that made the pain worse ( specific activities,

exercise food, medication)

anything that lessens the pain ( the pain in intermittentclaudication resolves rapidly on rest, avoidancemeasures )

Associated symptoms - pain rarely appears alone could be visual, aura as in migraine

numbness in the legs with back pain

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Radiation: ( referred by a shared neuronalpathway) diaphragmatic pain felt at the shoulder tip via the

phrenic nerve (C3,C4)

the pain of a prolapsed intervertebral disc usuallyradiates down the back of one leg

Timing: (duration**, course, pattern) since the onset, is the pain episodic or continuous

if episodic determine the duration and frequency

of attacks if continuous determine any changes in severity,

variation by night and day, during the week ormonth


Complaint (cont)

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Complaint (cont)

Timing / frequency ask what is relevant to the event

timing/frequency has to do with course and pattern

What time did it first come on?

Was the pain continuous or was it episodic?

How long does the pain last?

Interval between the episodes of pain?

If episodic determine the duration and frequency ofattacks

If continuous determine any changes in severity,variation by night and day, during the week or month

When was the last episode?

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Complaint (cont)

Severity:

this is difficult to assess

(at this point good enough to get an idea,

to compare and gauge various responses)

too subjective

tolerance for pain varies from person to person

maybe helpful to compare with other common pains (tooth ache)

use a scale (1 to 10) to have some impression to gauge pain in

the same patient

Previous episodes: (additional to OLD CARTS)

determine whether the patient has had a similar episode of this

particular pain before

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Once the patient was given a chance to tell his or her storyyou can ask more direct questions for clarification.

Examples : Directed or Closed Questions

Multiple choice

Do you have nausea? Vomiting? Constipation? Diarrhea?

Is the pain sharp, dull or shooting?

Have you had this for days, weeks or months?

Yes or No Questions

Do you have diarrhea every day?

Do you have any allergies?

Quantitative Questions

How many loose stools did you have in a day?


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{Additional questions only

when relevant}

Associated signs and

symptoms

have you noticed anything

else that accompanies it? Inquire about symptoms in

same body system

symptoms which are present

or absent e.g. patient with coughing blood phlegm, wheeze, chest pain

breathlessness


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FIFE:

Feelings related to the disease

Ideas on what is happening Functioning in terms of impact

on mood, relationships, job,

leisure, social life, sexual

activity

Expectations ( illness anddoctor)

Perhaps you could tell me whatyou think is causing your

problem?

What concerns you most aboutyour problem?

Im wondering what effect your

symptoms have had on your life ingeneral


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Past Medical History

General state of health Childhood: measles, mumps,

rubella, chicken pox, rheumatic

fever

Adult: hypertension,

cerebrovascular accident,

diabetes, heart disease, TB,venereal disease, depression,

chronic backache, cancer

Medical history

Surgical history

History of trauma

Obstetric and menstrual

history (when applicable)

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Past Medical History

Obstetric and menstrual history (cont)

Pregnancies

Birth Control

Health maintenance

childhood/ adult immunization

screenings

Hospitalization

In all cases (medical or surgical) record detailsof nature of illness, when it occurred,duration, treatment and outcome

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Medication History

Medicine name

Purpose

Dose

Route Frequency

Side effects

Taking as

prescribed? Cost issue

Use generic names

State what the medicine is for, dose,

route, frequency, side effects

Patient compliance?

Organize them by type, grouping

medications for a single purpose

together (i.e. antihypertensive, asthma

medications)

Include over the counter medications

Vitamins, Nutritional supplements

Herbal remedies.

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Allergies

Patients should be asked

about allergies or reactions

toanything including

medicines

Medications

What is the reaction?

Other substances, if severe

reaction

E.g. Peanut or bee sting

allergy

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Family History

Many diseasesrun in the family --

heart diseases,

diabetes

various

malignancies

some diseases

are directlyinherited --

e.g. haemophilia

F il Hi

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Family History

inquire about the health and if relevant the

causes of death of the parents, siblings &

children

symptoms similar to those the patient is

experiencing

screen for genetic and environmental

illnesses by asking about family history of:

diabetes, hypertension, stroke

heart disease, hyperlipidemia,

bleeding problems, anaemias

kidney disease, asthma,

mental illness, tuberculosis

history suggestive of a hereditary

condition (family tree)

cancer

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Social History

Social history describes (part of history often neglected)

behaviour of a patient personal habits

that may impact on disease,

increase risk

severity and outcome.

Occupation (from first job till present)

habits smoking, alcohol, recreational drugs

exercise, travels, hobbies,

attitude to his life and work

Housing

Smoking

calculate pack years 10 cigarettes per day divided by 20 X 15 years of smoking =

7.5 pack years.

> than 20 pack years, risk of COPD

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Review of System

The ROS is a head to toe survey to

uncover symptoms not elicited earlier inthe interview.

A list of routine questions to ask all yourpatients regardless of their complaints

Organized by organ system.

Any ROS items (positive or negative)relevant to the HPI should be transferredto the HPI.

Why do the ROS?

comprehensive patient care (of primarycare patients)

you will not miss key questions useful tothe HPI because you forgot to ask orpatient had overlooked to mention them

a fail-safe mechanism to make sure youdo not miss anything vital

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Review of System

C l ti th Hi t T ki i

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Completing the History Taking session

By now, you should havea list ofdifferential diagnosis.

Before you examine the patient briefly summarize what the

patient has said

this will allow the patient to add orto

correct anything you have missedout or misunderstood

Inform the patient that you aregoing to examine he / herand ask for permission andconsent before you begin thephysical examination.

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Thank You

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