General Principles of History - Taking

Lecture 1
MB;BS Year 1 (20112012) Dr. P Y Lee

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 of an accurate medical history # 5. appreciate the importance of effective communication

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?

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 your clinical competence Influences the precision
the diagnosis

investigations impacts on treatment

Importance Of Medical History

Directly reflects the quality of your work indicates your degree of discipline, exactness and thoroughness at bedside In the out-patient department 80% of diagnosis based on history Taking 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

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 physical examination 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 of possible conditions) failing which means a struggle to find signs on physical examination to confirm your suspicions

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

Briefly - Medical History

Also considered as part 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 consultation 6. use your clinical knowledge 7. for the benefit of your patient

History - Taking

Basically, there are five parts to a history. The Calgary-Cambridge scheme. initiating the session gathering information physical examination explanation and planning closing the session

Calgary Cambridge 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

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 the importance of building rapport with the patient. {In history-taking we deal only with the first two stages}.

Don'ts of History Taking

Do not interrupt the patient Do not use medical terminology Do not ask ambiguous or irrelevant questions Do not use leading questions in the first instance Do not be abrupt Do not rush the patient

Right to Refuse
Right to refuse: You should let the patients know that they are free not to answer any of the questions you ask and that they are free to terminate the interview at any time.

Confidentiality & Informed Consent

Confidentiality and informed consent: interview is confidential not absolute efforts made to protect the identity and dignity of the subject special situations when this is not respected e.g. reviewed by faculty small group discussion disclosed when the general public is put at risk

Symptoms and Signs Effective clerking must be systematically learned and practiced. Symptoms and signs: used synonymously till relatively recently a distinction made - 19th century, symptoms mean (subjective) complaints by the patient signs indicate the (objective) findings of the physician With each symptom, the details are obtained with OLD CARTS

Symptoms and Signs (cont) From the symptoms and signs you are trying to extract answers to five fundamental questions. 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?

Structure of a Medical History

Basic information about the patient 1. Presenting Complaint 2. History of Presenting Complaint 3. Past Medical and Surgical history 4. Medication history 5. Allergy 6. Family history 7. Social history 8. Systems review

How do you begin? Ask yourself what is the **first** objective you wish to achieve? to establish a good working relationship - 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.

Beginning an Interview

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.

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 and to confirm facts. 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 had

The key issue is to get a right balance of questions. All three types have a place.

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

Example: History of Presenting Complaint

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 in the process to elicit the history, begin with open questions Why have you come to see the doctor today? ideally, use the words of the patient

Example: Presenting or Chief Complaint (cont) Example:

Doctor: Hello, Mr Ahmad, what brings you in today? Patient: I am having this pain over my chest. Doctor: Tell me more about it. Patient: The pain is over the left side of my chest. It came on suddenly while I was watching football last night.
History of presenting complaint

Example: Presenting or Chief Complaint (cont)

Record the words that the patient actually used. do not substitute no abbreviations examples: patient rarely complains of dypsnoea, but will say short of breath Mr. Lee is a 56-yearold mechanic complaining of shortness of breath

History of Presenting
Once the chief complaint is established. Then expand on it. apply OLD CARTS to obtain
a detailed history that is complete, accurate and relevant diagnosis

Complaint

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)

History of Presenting Complaint

There are several broad questions which are applicable to any complaint OLD CARTS
Onset Location Duration Character *Aggravating factors *Alleviating factors *Associated symptoms Radiation Timing Severity

Explore in detail the circumstances surrounding the episode or event.

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) ??

Application of OLD CARTS in History Taking of Presenting 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 intermittent claudication resolves rapidly on rest, avoidance measures ) Associated symptoms - pain rarely appears alone could be visual, aura as in migraine numbness in the legs with back pain

Application of OLD CARTS in History Taking of Presenting Complaint (cont) Radiation: ( referred by a shared neuronal pathway) diaphragmatic pain felt at the shoulder tip via the phrenic nerve (C3,C4) the pain of a prolapsed intervertebral disc usually radiates 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 or month

Application of OLD CARTS in History Taking of Presenting 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 of attacks If continuous determine any changes in severity, variation by night and day, during the week or month When was the last episode?

Application of OLD CARTS in History Taking of Presenting 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

History of Presenting Complaint

Once the patient was given a chance to tell his or her story you 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?

History of Presenting Complaint {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

History of Presenting Complaint

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 and doctor)

Perhaps you could tell me what

you think is causing your problem? What concerns you most about your problem? Im wondering what effect your symptoms have had on your life in general

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)

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 details of nature of illness, when it occurred, duration, treatment and outcome

Medication History
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

Medicine name Purpose Dose Route Frequency Side effects Taking as prescribed? Cost issue

Vitamins, Nutritional supplements Herbal remedies.

Allergies
Patients should be asked about allergies or reactions to anything including medicines
Medications What is the reaction? Other substances, if severe reaction E.g. Peanut or bee sting allergy

Family History
Many diseases run in the family - heart diseases, diabetes various malignancies some diseases are directly inherited - e.g. haemophilia

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

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

Review of System
The ROS is a head to toe survey to uncover symptoms not elicited earlier in the interview. A list of routine questions to ask all your patients regardless of their complaints Organized by organ system. Any ROS items (positive or negative) relevant to the HPI should be transferred to the HPI. Why do the ROS?
comprehensive patient care (of primary care patients) you will not miss key questions useful to the HPI because you forgot to ask or patient had overlooked to mention them a fail-safe mechanism to make sure you do not miss anything vital

Review of System

Completing the History Taking session

By now, you should have a list of differential diagnosis. Before you examine the patient
briefly summarize what the patient has said this will allow the patient to add or to correct anything you have missed out or misunderstood

Inform the patient that you are going to examine he / her and ask for permission and consent before you begin the physical examination.

Thank You
Thank You