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Discussion:

1 In the first situation, how do you think the patient feels about being questioned on his

parents health? Does he give you any clues about feeling comfortable or uncomfmiable?

2 In the first situation, both of the patient s parents have had diseases with a familial

tendency. Do you think that most people realize that high blood pressure and bowel c?ncer

have a familial tendency?

If

so, how do you think it affects their health behaviors?

3 In the second situation, the parents discover that their young son has a cataract. How do

you think you would react emotbnally and intellectually to this news if it was your child?

4 In the second situation, both the mother and father are quick to p0int

o u ~

that there

1s

no

history of cataracts in their families. Why do you think that this is importcnt to them?

Reading Text

Patients most often seek care for a particular problem - a disease, illness or injury.

However, these problems cannot be treated in isolation. A patient may have more than one

problem, and so these problems interact making management more complicated. Also, a

patient s response to disease, and so their needs, are effected by their previous experiences.

For example, someone who

is

being hospitalized for the first time might be quite fearful of

the process, whereas someone who has been hospitalized previously may not be so

concemd Conversely, someone who is used to good health and quite con:B dent of their well

being may fat_;e disease or mjury with confidence, whereas someone who has had a series of

prcblem.> may

l>: Ve

feelings of depression and helplessness. These considerations

n1ean

that

the patient s hca:ith history

ca:1

give :r,1po1tant clues to tl;e special needs of the individual

patient.

The health history is also impmiant in identifying diseases which are hard to diagnose.

The careful history may reveal special chsracteris


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Situation

:

A well patient is having a pre-employment screening examination perfonned by

a nurse.

Nurse: Mr. Smith, I would like

to

ask you a few questions about your health history. Is that

alright?

Mr. Smith: Sure, go right ahead. But I ve always been quite healthy.

Nurse: Mr. Smith, have you ever been hospitalized?

Mr. Smith: I have only been in hospital once, when I was a kid. I had my appendix removed.

O ~ h e r w i s e I have always been pretty fit.

Nurse: Have you had any other operatior..s?

Mr. Smith: No, that was the only one. I ve 1lways been pretty healthy.

Nurse: Have you ever had any other serious illnesses?

Mr. Smith: Just the normal childhood diseases. Never anything serious.

Nurse: Mr. Smith, I am going to show you a list

of

diseases. Can you tell me if you have had

any

of

these? (The nurse runs down a list of diseases.)

Nurse: Diseases of the ears, eyes, nose or throat?

Mr. Smith: No.

Nurse: Disorders

of

breathing: asthma, bronchitis, emphysema?

Mr. Smith: No.

Tf _e nurse continues u;1til she finishes the list.

l Turse:

Well, Mr. Smith,

yo11

do

seem quite healthy.

Ivlr. Smith: (Joking) I told :rou so.

Nurse: Are you taking any medication right now?

Mr. Smith: No, nothing.

Nurse: Good. Now

if

you will just step into the examination room, the dortor would like

to

take a look at you.

Patterns

*Have you ever

... been hospitalized

... been in hospital

... been seriously ill

I have only

... been hospitalized once

...

been in hospital once

... been seriously ill once

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Have you had

any other operations

any other serious illnesses

I have always been

quite healthy

pretty healthy

pretty fit

Can

y o . ~

tell me/Please tell me/ Tell m

ifyoLI have had any

of

these

0 i s ~ a s e s

of

... the ears, eyes, nose or throat

0 Disorders

of

0 Illnesses effecting

Are you taking any medication right now

ituation 2: A physiotherapist has finished taking a specific history from a young patient

with bilateral knee pain. Now she is asking more general questions about the patient s health

history.

Physiotherapist: Apmi trom this problem, how has your health been?

Patient: Just the usual aches and YJains Nothing serious.

Physiotherapist: Well, have you had any other joint problems?

Patient: Sometimes my shoulders hurt. Do you think that has anything

to

do with my knee

pain?

Physiotherapist: It could be related. Do the two problems seem to occur together?

Patient: Not really - they don t seem to come on together. The knees usually bother me in the

morning. The shoulders only bother

m

hen I have been working at the computer.

Physiotherapist: Well then, they are probably not related. How ahout skin problems- any

~ c z e m a or p s o r i a s i ~

Patient: Occasionally I seem to have some psoriasis on my elbows. Could that be related to

the knee pain?

Physiotherapist: Sometimes they go together. How long have you had the psoriasis?

Patient: Actually, I haven t had a problem with it since I finished university a year ago.

Physiotherapist: Then it is probably nothing to worry about. How is your digestion? Have

you had any problems with your stomach or bowels?

Patient: Previously, I had quite a nervous stomach, although that hasn t been a problem

recently.

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Physiotherapist: Are there-any other health problems that you think I should know about?

Patient: Not really. I haven't had any big problems lately_

Physiotherapist: In that case, I'd like to examiae your knees now.

Patterns

*Have you had

... any other joint problems

... any problems with your stomach or bowels?

How

about

... skin problems

How

is

... your digestion

* Do you think

...

that has anything to do with

my

knee pain

* Could that be related to

... the knee pain

* Do the two problems seem to go together

They don't seem to

... come on together

* Sometimes they

...

go together

*

t

could be related

...

Sometimes ...

my

shoulders hurt

* Occasionally ... I seem to have some psoriasis

* Previously ... I had quite a nervous stomach

* I a v e n ~ had

...

a problem with it since I linished tllli\ ~ : s i t y

* That hr.sn't been a problem recently

* I haven't had any big problems lately

They are probably ... not related

* t is probably nothing to worry about

Discussion

1.

In situation

1

Mr. Smith talks about normal childhood diseases. What are the normal

childhood diseases in Japan? Are they likely to

be

the same

as

the normal childhood

diseases in Mr. Smith's home country?

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2.

Mr. Smith seems to think that normal childhood diseases are not serious. What is your

opinion? Can you think

of

some examples to justify your opinion?

3. In

situation 1, the nurse has a list

of

diseases that she shows to her patient. There are

countless diseases, and they can't all be listed. How would you choose the diseases to put

on a list for screening patients?

4. In

situation 2, the patient talks about the "usual" aches and pains. Is it "usual" to have pain?

5. In situation 2, both the physiotherapist and the patient talk about problems being "related".

What does it

-::eally

mean when we talk about two diseases being "related"?

Reading Text

An essential part ofpatient care is determining what is wrong with the patient that is

making a diagnosis. Delaying the diagnosis because of communication problems means

delaying proper treatment. Poor communication may also result in the wrong diagnosis, so

that the patient receives care which is ineffective or even dangerous. Consequently, effective

interviewing of the patient, also called history-taking, is an important clinical skill.

When communicating with the patient who does not speak your language well, you

must take the time to confirm information. However, you also have to think of the limitations

on your time- you have other patients who also need your attention. Additionally, a long and

protracted interview is stressful for both you and the patient. Try to be efficient and accurate,

but realize that you may need a little more time than with your Japanese patients in order

check your information carefully. You may find that using chmis or pictures helps you to

gather more

c c t ~ r t e

ii1f0rmat:on.

When taking a patient'::; Listm-v, you J:Iust th r.k c&refully about

vv'hat

is " 1ice to know"

as compared to what you "need to know". In the patient interview, we concentrate on what

we need

to

know. What are the essential details that you need to ~ n o w about a patient's

presenting complaint in order to make a diagnosis? You have pr8bably memorized, or will

meme>rize, a list of essential points that you question every patien about. If you haven't done

this already, pause now and make your own list of essential questions.

Ninety percent of the time, or more, you can make a diagnosis from the patient history

without any additional tests. Of course, tests are important to confirm your diagnosis.

However, you should generally be able to get enough information from the patient interview

that you can confiden'

1

:

make a working diagnosis of the presenting complaint.

Situation

:

A 12 year old boy with shortness ofbreath is brought

to

a clinic

by

his mother.

Doctor:

Jright,

John. Please tell me what the problem is.

John: Sometimes I really get out

of

breath. I can hardly breathe

at

all.

Doctor: How long have you had this problem?

John: Just this summer. Lr.::t year l was fine, I think.

Doctor: Mrs. Smith, has John ever had a problem like this in the past?

Mrs. Smith: Actually when he was four or

five years old,

he

seemed to have a touch of

asthma, but it cleared up when he started school. That was in New Zealand.

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Doctor: And when did you come

to

Japan?

Mrs. Smith: About a year and a half ago. But last summer he was fine.

Doctor: John, is there a tir..1e of day when your breathing seems worse or hetter?

John: Probably its worse in the morning, but any time if I run I have trouble breathing.

Doctor: And is there anything that makes it feel better?

John: Well, ifl am running, I just stop running.

Doctor: And how long does it take you to feel better if

you stop running.

John: Sometim:::s just t couple ofminutes, sometimes

l o : ~ g e r

Doctor: Do you think it has gotten worse lately?

John: Well, actually, it has been pretty bad the last couple of weeks.

Doctor: Mrs. Smith, have you given John any medication for this?

Mrs. Smith: No, at first he didn t really complain about it, and then we realized that it might

be asthma again.

Doctor: You re right. t looks like asthma, but we should do a few tests.

Patterns

*Please ... tell me explain describe

...

what the problem is

...

what is wrong what

is

bothering you

How lo:1g have: you

...

had this problem had these symptom >

*How long has this e ~ n

both ::ri:1g

you?

* Have you ... ever had a problem like this had this

.in the past before

*Is this the first time you have had this problem?

Is there

... a time of day when your breathing seems wmse/better

...

anything that makes your get worse/improve

... something that you do that makes you feel ...

How long does it

...

take you to feel better

... take you to recover

... take for the medicine to work

Do you think feel

..

.it has your symptoms have, you have

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0 gotten worse

I

improved

I

changed

0

..

.lately I recently

Have you

...

given John

I

taken

I

received

0 ...

any medication

I

medicine

I

other treatment

Situation

2: A

man

with low back pain is being interviewed by his chiropractor.

Chiropractor: Can you show

me

where the pain is?

Man: Well it starts here (running hand around buttock) and runs down my leg.

Chiropractor: Does t1e pain go below the knee?

Man: It s hard to say.

N y

whole leg feels tight.

Chiropractor: Well, where is the worst pain?

Man:

My

buttocks.

Chiropractor: Is the pain only on the right side?

Man: At first it was, but now the left side is also pretty tight.

Chiropractor: But is it worse on the right than on the left?

Man: Oh, definitely.

Chiropractor: And how bad is the pain, on a scale

of

0 to 10?

Man: Maybe 7 or 8 out of 10. Worse

if

I cough or sneeze.

Chiropractor: How would you describe the

pain

when you cough

or

sneeze?

Man:

I t ~

:

really sharp pain.

t

shoots right down

my

leg.

Chiropractor: Are you able to sleep at night?

Man: Not very well. I always have this intense ache around my buttock.

Chiropractor: Is there anything else that the pain prevents you from doing?

Man: Sit ting is worse than standing. And this is kind of embarrassing, but it is hard to go to

the

o i l ~ t

Chiropractor: Actually, what you are describing is quite ~ o m m o n

Patterns

Can

you

... show

me

where

I

tell

me

where

I

describe where

... the pain is

I

it hurts

I

the problem is

Does the pain

... go

I

spread. radiate

0 ...

below the knee

I

down the arm

I

anywhere

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* Where ... is the worst pain is the center of the pain

...does it hurt the most

Is

... the pain it

D

...

only on the right side

D ... worse on the right than on the left

D the same on both sides

How

... bad severe painful

D is the pain the problem it

* How would could do you

describe rate

D o the pain problem it

D .o. if you cough when you stand at the moment

Are you able to Can you Do you

o

0 sleep

at

night

* Is there anything (else)

o that the pain prevents you from doing

o that you can t do because

of

the pain

that makes the pain worse/better

* \Vhat you are describing is That is

quite common natural understandable nothing to worry about

Discussion

10

In situation 1 the r loctor finds that the young boy s condition developed recently, and is

getting worse What does this lead you to think about the prognosi..,

2.

Ill

situation

1

we find that the young boy hrrs had a similar condition in the past. What

questions might you ask about the previous condition?

3. In the first situation, the mother suspected that the child had asthma. Why do you think that

she didn t immediately offer her opinion on the cause of the boy s symptoms?

4. In situation 2 how would you measure the patient s pain?

Is

there a relinble way to

measure how severe a patient s pain is?

5. What other questions might you ask about a patient s pain in order to establish a diagnosis?

reading text 8

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