obtain a health history ref(s): c1 - bates “a guide to physical examination”, eighth edition

Obtain a Health History

Ref(s): C1 - Bates “A Guide to Physical Examination”, eighth Edition

Obtaining a health history

• The Health History Interview

• Techniques of skilled interviewing

• Components of the Comprehensive Adult History

Health History Interview

Health History:– A structured framework for organizing patient

information in a written or verbal form.– Focuses the clinician’s attention on specific

pieces of information that must be obtained from the patient.

The interviewing process:– Generates the pieces of information in a fluid

manner.


Conversation with a purpose– To improve the well-being of the patient:

1. Establish a trusting and supportive relationship

2. Gather information.

3. Offer information.


You need to focus your energy on gathering information while:

– Letting the patient’s story “unfold”

– Generating a series of hypotheses about the cause of the patient’s concerns and

– Still find a way to explore the patient’s “feelings and beliefs about their problem(s)”.


The challenge:

“Every man is….like all other men…like some other men,…like no other man.”(Barbara Bates)

Remember that few patients are “competent” story or history tellers…in the way that you want them to be.


Who are we talking with?

Why has the patient come?

What do we want to know?

What does the patient expect of us?

What more information do we need to solve the problem?


Before you begin:

1. Taking time for Self-reflection– How can you remain or become consistently open

and respectful to individual differences?

– Everyone brings their own beliefs, values, and experiences to each patient encounter…how will that affect what you are about to hear and how will you respond to it?


2. Reviewing the Chart– Problem list

– Medications

– Allergies

– Past diagnoses and treatments

– The chart or ER triage sheet does not, “capture the essence of the person that you are about to meet”


3. Setting Goals for the interview

Provider centered goals:– Write-up for your supervisor– Insurance form

Patient centered goals:– Relieve the pain– Note for work

There has to be a balance between the above as well as the institutional needs.


4. Reviewing Clinician Appearance and Behavior

What do patients look for in appearance?

Posture, gestures, eye contact, and tone of voice can all express interest, attention, acceptance and understanding.

But they all have the potential to express the opposite!


5. Improving the environment

– How do you make a room(s) more private or more comfortable?

6. To take notes or not to take notes?

– If you need to use short phrases, specific dates, or words not the final version of what a patient said?

– How do you respond to, “your note taking is making me uncomfortable?”


The sequence of the interview:

1. Greeting the patient and establishing rapport.

2. Inviting the patient’s story.

3. Establishing the agenda for the interview.

4. Expanding and clarifying the patient’s story: generating and testing diagnostic hypotheses…Q and Q!!!

5. Creating a shared understanding of the problem(s).

6. Negotiating a plan. (further evaluation, treatment and patient education)

7. Planning for follow-up and closing the interview.

Greeting the patient and establishing rapportIntroduce yourself. • Great patient appropriately in a friendly relaxed way.

– Shake hands (if possible).– Explain your role in the patient’s care and status (as a student)

• Note – never forget patient names and use titles.

• Confidentiality is paramount– Know who is in the room, their relationship to the patient and whether or not he or she

should stay in the room.

• Be sensitive to the comfort of the patient:– Bedpan vs. pain vs. other tests taking place

• Arrange the room appropriately:– Do not have objects between you and the patient when avoidable.– Avoid arrangements that connotate disrespect or inequality of power

• Consider the need for a chaperone nurse/ Med Tech

Inviting the patient’s story

Open ended questions to elicit the Chief Complaint:– “What concerns bring you in today?”

– “How can I help you”

– “You have had this problem for seven weeks, what made you decide to seek medical treatment for it today? What has changed?”

Listen without interrupting!

Inviting the patient’s story

Following the patient’s lead:• Initially - “continuers”• Try to hone in on the most significant things using “Direct

questions”.• Consider asking questions that require a graded response. • Consider offering Multiple Choice answers.• Ask one question at a time.• Use language that is understandable and appropriate?• Clarify what the patient means but in terms they can

understand.

Expanding and clarifying the patient’s story

Language is important:– Shortness of breath vs. dyspnea

– Bright red blood in your stools vs. hematochezia

Establishing the sequence and time course of the presenting problem is also important.– It is now 1200, to the best of your knowledge when exactly did the

pain start?

Establishing the agenda for the interview.

Both the patient and the clinician have goals in mind…they are not always the same.

As a student you usually have more time per patient; this changes as you become a clinician.

Agree upon the goals at the beginning of the encounter and then you can move forward.

Expanding and clarifying the patient’s story

Each symptom has attributes that must be clarified, including context, associations, and chronology…the most obvious and ( very common) being that of “pain”.

Remember: the “seven attributes of a symptom”.

Symptom attributes

1. Location: Where is it? Can you point to it? Does it radiate?

2. Quality: What is it like?3. Quantity or severity: How bad is it?4. Timing: When, how long, how often?5. Setting in which it occurs: environmental and

personal activities.6. Remitting or exacerbating factors.7. Associated manifestations.

Essentially, by asking the right questions you are generating and testing diagnostic hypotheses through engaging the patient’s perspective.

To do this well you must understand the pathophysiology of disease and the patterns of disease. How do you gain this knowledge?

Studying, seeing real patients, studying, seeing real patients, reviewing and studying, and SEEING

REAL PATIENTS!!!!!!

Creating a shared understanding of the problem(s).

The seven attributes gives you the details but you also need to explore the following terms to consider a dual view of reality for the interview to be successful… disease vs. illness:

– Disease: explanation that the clinician brings to the symptoms.

– Illness: how the patient experiences symptoms. What factors may shape this experience?


Exploring the patient’s perspective:

1. Pt’s thoughts about the nature and cause of the problem.

2. Pt’s feelings, esp. fears about the problem.

3. Pt’s expectations of the clinician and healthcare.

4. The effect of the problem on the patients life.

5. Prior personal or family experiences that are similar.

6. Therapeutic responses that the patient has previously

tried.


IFFE: • What do you think is causing the problem ( Patient’s best Idea of what

is causing the problem?

• What is your worst Fear that the problem could be?

• How is the problem affecting your Functioning?

• What are your Expectations of this visit?

Negotiating a plan

Create a plan that is feasible for you and the patient…not just you!

e.g. The case of the patient that does not get sick leave or is self-employed with few or no benefits.

Planning for Follow-up and Closing

Maybe difficult…if you are doing well so far the patient likes talking to you and chances are they would like to continue.

Ensure that the plan has been agreed upon and summarize the plan…or better yet have them summarize it.

Do not get into discussion of new topics as you are leaving if you can avoid it. Reassurance is adequate if it is not a life or limb threatening concern.

Techniques of Skilled interviewing

Active listening:– Fully attend to what the patient is communicating being

aware of the pt’s emotional state.

Adaptive Questioning:– Directed questioning from general to specific.– Questioning to elicit a graded response.– Asking a series of questions, one at a time.– Offering multiple choices for answers.


Non-verbal communication

– Eye contact, gestures, facial expression, posture, head position and nodding or shaking, personal distance, crossed arms or legs.

– Matching your position to the patient: eye to eye, or reasonable physical contact with the patient.


Facilitation: – using posture, actions or words to encourage the pt to

say more. I.e. “mmm go on”, “I’m listening”, maintaining eye contact, or leaning forward in the chair.

Reflection/echoing: – a simple repetition of the patients words, I.e. Pt “The

pain got worse and started to spread”? Clinician “Spread”?


Clarification:– Some patients words are ambiguous and require further

discussion, I.e. What do you mean when you stated “I have a cold”, “I don’t feel like my usual self”.

Empathy:– Offering some one a tissue during a moment of distress

or simply stating “I understand”, “you seem sad.”, or “That sounds upsetting.”, “ This is a very difficult challenge for you”


Validation:– Legitimize their emotional experience. “That must have

quite terrifying.”

Reassurance…in a proper manner.– You need to identify and accept the patient’s feelings

without offering reassurance at that moment and allow the reassurance to come later…once you have all the necessary information and concerns can be openly addressed.


*Summarization:

– Lets the patient know that you have been listening.

– Picks up any missed information or misinterpretation of information.

– Organizes your clinical reasoning, conveys your thinking to the patient and makes the relationship less one sided and more collaborative.


Highlighting transitions– “Now I would like to ask you some questions

concerning your past health.”

Taking a History on Sensitive Topics

• Drug / Etoh abuse• Sexual orientation or habits• Death and dying• Financial concerns• Racial and ethnic experiences• Family interactions• Domestic violence• Psychiatric illness• Physical deformities• Functioning of the Urinary Tract / Bowels, etc..

Basic principles

• Maintain a non-judgemental approach.

• Explaining to a patient why you need to know the information and putting it into context is very helpful.

• Use ”specific language”!

Other ways to become more comfortable

• Reading about these topics.

• Talk to selected colleagues.

• Talk to teachers about your concerns.

• Listen to experienced clinicians when they

have to discuss certain topics with a patient.

• Be aware of Bias and cultural difference!

Culture

• A system of shared ideas, rules, and meanings which individual inherit or acquire that tells them how to view the world, how to experience it emotionally, and how to behave in relation to other people and to the environment.

The Goal

• Become aware of your own biases and values.

• Develop communication skills that transcend cultural differences.

• Build therapeutic partnership based on respect for the patient’s life experiences.

Self-awareness

How do you define yourself by:• Ethnicity• Class• Region• Religion• Political affiliation• How are you the same or different than your

family of origin?

Values vs. Bias

Values - standards we use to measure beliefs and behaviors…which may appear to be absolute.

Biases - the attitudes or feelings that we attach to the awareness of differences.

Learning about others

Can you be an expert on every person’s culture?• Patients are experts on their own unique cultural

perspective.• Be ready to acknowledge your own ignorance or

bias.• Learn about ethnic or racial groups in your region

or if you are going to work in a different region as a start.

Adapting Interview Techniques

The Silent Patient

• Silence: collecting thoughts, remembering details, deciding on trusting you with info.

• Non-verbal clues: emotion, unable to sit still.

• Are you asking too many questions in sequence?

• Have you offended them in any way?

• Are they too short of breath to answer your questions?


The Talkative patient

• Do you give them “free reign for 5-10 mins”?

• Focus on what is important for the patient, you may need to interrupt but be courteous.

• A brief summary may help you change the subject yet validate any concerns.

• It is important to not show your impatience.


The Anxious Patient

• It is a frequent reaction to sickness, treatment, and the healthcare system itself.

• It is also maybe part of their illness.

• Watch for verbal and non-verbal clues.

• If you detect anxiety, reflect your impressions back to the patient and encourage them to talk about any underlying concerns.


The Crying Patient

• Emotions: sadness to anger to frustration.

• Maybe therapeutic for the patient.

• Most patients will recompose themselves and continue with their story…as opposed to escalating or becoming uncontrollable.

• Does a crying patient make you uncomfortable?


The Confusing Patient

• “ a positive review of symptoms”

• Focus on the meaning or function of the sx as part of a psychological assessment.

• You may become baffled, confused, or, as is usually the case, frustrated yourself.

• “my fingernails feel too heavy”

• Be aware of any neurological, psychiatric, or intoxication in patients like this as well as any language barriers…get more info from loved ones with permission from the patient.


The Angry or Disruptive patient

• Reasons: ill, suffered a loss, felt powerless within the healthcare system…they may direct this anger towards you.

• Did you do anything wrong? Can you correct it or at least apologize so you can move on.

• You can validate their feelings without agreeing with their reasons.


• What do you do when patients become hostile or disruptive?

– Inform security, hear what they have to say, do not appear challenging in posture, and suggest moving to another location that is not upsetting to other patients and offers more privacy or less privacy given the situation.


The Patient with a language Barrier

• “Nothing will convince you of the importance of a history then having to do without one.”

• Make every effort to find an interpreter.

• A neutral objective person who is familiar with both languages and cultures.

• Family members may: speed things up, violate confidentiality, distort meanings, transmit incomplete information, and may have their own agenda.

Global CompetencyGlobal Competency

Overall technique of applying the knowledge of the skill

Greeting patient & Introduction

Establishing Rapport:• Look confident & professional approach.• Non verbal communication- looks & talk friendly manner, show

interest & seriousness regarding patient’s problem.

Logical sequence of questioning.• If a procedure is required explain the procedure & obtain informed

consent.• Assurance of the procedure & confidentiality.

.

Follow cues & proper interaction with the patient.

Use open & direct question appropriately; avoid medical jargon & ensure patient understand, also ask the patient to explain any vague terms that they use.

Avoid unnecessary repetition.

Comprehensive Adult History

Demographic Data

Chief complaint.

History of present illness (HPI).– Medication/Allergies.

Past Medical History.

Personal and Social History.

Family History

Review of Systems.


• Comprehensive vs. focused (problem oriented) interview

• Components structure the patient’s interview and the format of the written record…but do not dictate the sequence of the interview!


Demographic (identifying) Data– name– age– gender– occupation– marital status– (years of service)– Source of the history– Include date and time of the hx being taken– Consider if the hx is being given from a reliable source


Chief Complaint

– use the patient’s own words.• “ I can’t breathe properly.”

– more than one chief complaint (C/C) let the patient (Pt) put them inorder of importance, as they see it.

– Might be as simple as” I need a note for work.”


History of Present illness (HPI)

– Complete, clear, and chronologic account of the problems that the patient is trying to obtain care for.

– Sx’s need to be well characterized with descriptions focusing on the common seven attributes for understanding all patient sx’s:

Comprehensive Adult History - HPI

1. Location: Where is it? Can you point to it? Does it radiate?

2. Quality: What is it like?3. Quantity or severity: How bad is it?4. Timing: When, how long, how often?5. Setting in which it occurs: environmental and

personal activities.6. Remitting or exacerbating factors.7. Associated manifestations.

Principal Symptoms Description

Pain– CHLORIDE PPPS– OLDCART– OPQRST

Other presenting sx’s i.e fatigue, SOB, vertigo, unwell, vomiting, diarrhea, etc…– OLDCART– OPQRST

DDx list

CHLORIDE PPPS

Ch –Character

L – Location

O – Onset, gradual vs sudden

R – Radiating

I – Intensity

D - Duration

E – Events surrounding cc

P – Palliative

P – Provoking

P – Previous episode

S – Sx’s associated

Chloride PPP…s

•Most Basic H&P taught on the PA course

•Designed as an effective approach for someone presenting with a complaint of “Pain” e.g. chest, abdominal, leg, etc…

•Completely appropriate for the junior clinician.

–Minimizes risk of missing questions when you don’t know what is wrong or which are the most crucial questions to ask

Chloride PPP…s

Is the testing framework for some but not all of the phase one Practical EC’s…regardless all P-EC’s require Q&Q of sx’s…so will every future patient encounter in your clinical practice.

Chloride PPP…s

• It is one of several methods used to “qualify and quantify” the patient’s complaint of pain

• “Sudden onset of mid-sternal crushing chest pain radiating to the left shoulder and jaw occurring with exertion lasting 15 mins made worse with activity and improved with rest, with no previous episodes and no association with trauma... initially was 9/10 and now is 4/10.”

Chloride PPP…s

• The “s” component stands for “symptoms associated”…it is the most important part and a challenge for the junior clinician to pick out what are most important associated sx’s to ask about to rule in a Dx and rule out other vital differential diagnoses

– E.g. Sob, palpitations, cough, LOC, nausea, vomiting, PND, Orthopnea, edema, fever,etc…

– To help in differentiating cardiac and non-cardiac causes of chest pain

Chloride PPP…s: Disadvantages

• Design is not good for other presenting complaints: “SOB”, “Fatigue”, “don’t feel well”

• Can be very inefficient for most experienced clinicians

• Can be difficult to present in an orderly fashion to most physicians without them losing interest…particularly specialist consultants.

• Why do you use it…because you do not know which of the questions are most important yet.

Studying, seeing real patients, studying, seeing real patients, reviewing and studying, and SEEING REAL PATIENTS!!!!!!

Essentially building a clinical data base that you are going to selectively access information from on an as needed basis…to formulate a clinical plan.

Chloride PPP…s: Disadvantages

• Difficult to sort through for a final disposition for the patient (lose the forest for the trees) unless combined with some of the following techniques.– E.g.“VINDICATE” or using an anatomic

approach - is a way to fill in the “S” part of chlorideppps

• Also the short list, systems approach, diagnostic template among others

OLDCART

O – Onset

L – Location

D – Duration

C – Characteristics

A – Aggravating Factors

R – Relieving Factors

T – Time it occurred

OPQRSTOnset of disease Position/siteQuality, nature, character – burning sharp, stabbing,

crushing; also explain depth of pain – superficial or deep.Relationship to anything or other bodily function/position. Radiation: where moved toRelieving or aggravating factors – any activities or positionSeverity – how it affects daily work/physical activities.

Wakes him up at night, cannot sleep/do any work.Timing – mode of onset (abrupt or gradual), progression

(continuous or intermittent – if intermittent ask frequency and nature.)

Treatment received or/and outcome. Are there any associated symptoms? Check with R.O.S.

VINDICHATEM

V - VascularI - Infectious/InflammatoryN - NeoplasticD - degenerativeI - Idiopathic, IatrogenicC – CongenitalH - HematologicalA – Autoimmune T – TraumaE - EndocrineM - Metabolic

Current Health Status

Medications taken – to include home remedies, herbal supplements

– prescription and non-prescription

Allergies– environmental

– medications

– foods


Past Medical History (PHx) Purpose to identify all major health issues of the Pt.

– A. Childhood diseases: • Measles, rubella, mumps, chicken pox, polio, rheumatic

fever, scarlet fever– B. Adult illnesses (divided in four categories):

1. Medical ( DM, HTN, CAD, Asthma)2. Surgical and/or injuries ( dates, indications)3. Obstetrical / Gynecological4. Psychiatric

C. Health Maintenance• Immunizations, Screening Tests i.e CXR, PSA,

mammograms


Personal and Social hx – Occupation and last year of schooling

– Home situation and significant others

– Stressors: recent and long-term

– Leisure activities

– Exercise and dietary habits

– Drug, alcohol, and tobacco usage

– Religious affiliation and spiritual beliefs

– Activities of Daily Living

– Safety Measures

– Alternate Health Care Practices


Family History (FHx)

Pertinent health of patients blood relatives to include all immediate relatives:– Parents– Siblings– Grandparents– Children– Grand children


Determine the occurrence of the following:– diabetes - headaches– tuberculosis - mental illness– Asthma - COPD– heart disease - Elevated Cholesterol – high blood pressure - stroke– kidney disease - Seizure disorder– Cancer - Alcohol or drug addiction– arthritis– anemia

– When doing a focused Hx you should concentrate on the disease processes that are related to the Symptoms / disease that the Pt is presenting with!!!!


Review of Systems (ROS)– Or Functional Inquiry

– Consider it to be a “head to toe assessment”

– Remember to use layperson’s language

ROS

General or Usual state of health

• Episodes of chills, weakness or malaise• Fatigue• Sweats• Usual weight including gain or loss of weight

Skin

Any changes in skin color, nails or hair– brittle hair, alopecia, clubbing, or paronychia

Any of the following: - rashes, sores, lumps, moles, infections, lesions,

masses, eruptions, general or localized

pruritis

EO 001.01 R.O.S

HEENT

• Head• Eyes• Ears• Noses & Sinuses• Throat / Mouth & Neck

Head:– Any hx of head trauma or headache.

EO 001.01

Eyes

Determine the fol:– vision changes with most recent eye test results– Visual field changes– ocular pain– pain with eye movement– redness– irritation

EO 001.01

Ears

Ascertain the fol:– tinnitus– hearing loss (acuity)– earache– Infection with or without drainage/discharge– vertigo

EO 001.01

Nose & Sinuses

Sense of smell– cranial nerve I

Common ailments:– stuffiness/congestion

– bleeding

– discharge

– sinus pain

EO 001.01

Mouth, Throat, &Neck

Common ailments:– bleeding

– sores

– lumps

– frequent sore throat

– voice change/hoarseness

– difficulty swallowing - dysphagia

EO 001.01

BreastsSigns / Symptoms

– Lumps / nodules– Pain / tenderness– Discharge

Is self-examination performed?

Last Clinical Breast Exam (CBE)?

Mammograms in the past?

EO 001.01

Respiratory

• Cough(productive/dry)

• Sputum (color, amount, smell)

• Haemoptysis

• Chest pain

• SOB

• Increased RR

• Wheezing

• Chest X-Ray– Date and result

EO 001.01

Cardiac

• Chest pain, Palpitations, claudication

• SOB, Cough

• PND, Orthopnea, Edema

• Syncope or pre-syncope

• Base-line or previous EKG/Stress Test

EO 001.01

Gastrointestinal

Common ailments:– appetite < or >– dysphagia / odynophagia – n & v– heartburn– reflux– jaundice– indigestion– abd pain

EO 001.01

Gastrointestinal

Bowel movements?

– What is normal for them? Daily or not.

– constipation/diarrhea

– hematochezia

– Melena

– hemorrhoids

EO 001.01

Urinary System

Is the patient suffering from:– Dysuria

– Frequency

– Urgency

– Nocturia

– Hematuria

– Hesitancy

– Decreased stream

– Dribbling post voiding

EO 001.01

Genito-Reproductive Male

Penile discharge– how often

– color

– blood

– odor

Pain and/or lesions– occurrence

– location

– frequency

EO 001.01

Genito-Reproductive Male

Hx of STD’s– # of exposures

Testicular pain– location– Swelling– Self-examination

Sexual problems or concerns

EO 001.01

Genito-Reproductive Female

Menstruation– age of menarche– regularity– frequency and duration– last menstrual cycle (LMP)– abnormal menses (discharge/pruritus)– amount of bleeding

last gyne exam and PAP smear resultsHx of STD’sDyspareuniaOvarian cystsMenopauselibido

EO 001.01

Obstetrical Hx

• Number of pregnancies• Full term deliveries (vaginal or C/S)• Abortions (spontaneous and/or therapeutic)• Complications of pregnancy• Infertility• Method(s) of contraception used• Familial obstetrical hx (if relevant)

EO 001.01

Musculoskeletal

Extremities– joint or muscle

– location

– severity

– aggravating/relieving factors

– with movement

– swelling

– ROM

– temp sensitive

EO 001.01

Neurologic - CNS/PNS

• Syncope - Abnormalities in sensation• Seizures - Abnormalities in coordination• Weakness and balance• Numbness/Tingling• Tremors• CVA/TIA sx’s• Memory loss• Involuntary movements• Headaches, visual sx’s

EO 001.01

Psychiatric Hx

• Humor, Anxiety, Depression, Mood changes• Nervousness, Irritability• Sleep disturbances, Memory changes• Attention, concentration• Hallucinations, delusions• Suicidal / homicidal ideation

EO 001.01

Endocrine System

Common ailments– polyuria

– polydipsia (thirst)

– intolerance to temp change

– excessive sweating

– weight changes/problems

– Hair/skin changes

– GU related problems

EO 001.01

Hematologic

Bleeding– hx of abnormal/excessive bleeding

– duration

– any transfusions

Bruising– ecchymosis

EO 001.01

SOAP FORMAT

SOAP

Subjective- how patient feels/thinks about him. How does he look. Includes CC and general appearance/condition of patient

Objective - relevant points of patient complaints/vital sings, physical examination/daily weight, fluid balance, diet/laboratory investigation and interpretation

Assessment – address each active problem after making a problem list. Make differential diagnosis.

Plan – about management, treatment, further investigation, follow up and rehabilitation

ANY

QUESTIONS???

obtain a health history ref(s): c1 - bates “a guide to physical examination”, eighth edition

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