Communication with surgical patients (Surgical history taking) Prof. Galal Abouelnagah, FRCS, PHD, MD Prof & head of Surgical Oncology unit Faculty of Medicine Alexandria University

Objectives Define effective history taking Describe components of patient history Outline patient interviewing techniques Identify strategies in obtaining history Techniques facilitating History Taking Special challenges

What is it? Patient interview in systematic way to: Patient interview in systematic way to: Recording necessary medical information Recording necessary medical information + Classical examination signs All information must be documented precisely and accurately

Importance Help for reaching diagnosis Help for reaching diagnosis Help in formulation treatment plan Help in formulation treatment plan Evaluate medical progress Evaluate medical progress Medico-Legal record Medico-Legal record Availability of information for: Research Reportable diseases Insurance claims

Example أنا تعبان جدا يا دكتور. والتعب بدأ معايا من مدة. رحت لدكاترة كثيرة كتبوا لى روشتة. عاوزك تشوف لى حل. أنا خلاص تعبت و ما عدتش مستحمل. كله بيوجعنى. مش عارف أعيش خالص. أنا تعبان جدا يا دكتور. والتعب بدأ معايا من مدة. رحت لدكاترة كثيرة كتبوا لى روشتة. عاوزك تشوف لى حل. أنا خلاص تعبت و ما عدتش مستحمل. كله بيوجعنى. مش عارف أعيش خالص. What the disease of that patient? What the disease of that patient? Which body system is affected? Which body system is affected? Since when disease started? Since when disease started? What treatment he received & does it help? What treatment he received & does it help?

Types of patient interview Initial history taking Initial history taking Inward daily round: progress of condition, results of investigations, respond to treatment Inward daily round: progress of condition, results of investigations, respond to treatment Discharge interview: plain at home Discharge interview: plain at home Follow up visit: New symptoms & signs since last visit, drug management Follow up visit: New symptoms & signs since last visit, drug management Field research or screening questionnaire Field research or screening questionnaire

Not just completing a form Not just completing a form Tell patient your name and explain why you are seeing him Tell patient your name and explain why you are seeing him More important for medical students Could be started before patient’s talk Could be started before patient’s talk Give patient whole your attention Give patient whole your attention Doctor should be an empathetic listener Doctor should be an empathetic listener General rules

Consent Type of consents: Type of consents: Oral Oral Behavioral Behavioral Written consent Written consent Why: Why: To get adequate information about case To get adequate information about case Avoid medico-legal complains Avoid medico-legal complains

Set the stage Provide safe environment Provide safe environment Your behavior and appearance Your behavior and appearance Shake hands Shake hands Avoid the patient’s personal space Avoid the patient’s personal space Inquire about patient’s feelings Inquire about patient’s feelings Avoid unfamiliar or street terms Avoid unfamiliar or street terms Note taking Note taking Signs of uneasiness Signs of uneasiness

(Body Language ) (Body Language )

ActionSignificance الإبتســــــــــامــــه. الارتياح أو الرضا أو الموافقة قضــــــــــم الشفاه. العصبية أو الغضب أو الضيق.

رفع الحواجب مع أو الكتف. المفاجأة أو عدم التصديق أو الدهشة رفع الحواجب مع ابتسامه مصطنعة التهكم أو السخرية. تضييق العـــــــــــين عدم الموافقة أو الشعور السلبى

 الانحناء للإمام الاهتمام أو العناية. الحركة الكثيرة فى الجلسة القلق أو السأم أو التعب الاستقامة والاعتدال فى الجلسة. الثقة بالنفس.

تركيز العين فى عين الطرف الآخر الإنصات أو تركيز الانتباه تجنب تلاقى الأعــــين. التجنب أو اللامبــــالاة أو العصبية. التثــاؤب. الملل والضجر.

Guidelines for taking case history Questions should be open ended (encourage) Guidance of conversation but not restricting Avoid leading questions (‘yes’ or ‘no’ answers) Clear & specific questions Ask one question at a time Cover various aspects of diseased organ Direct questions may be required sometimes Patient symptoms in his own words??

Special situations Infants under 5yrs; parent is interviewed Infants under 5yrs; parent is interviewed Unconscious patients Unconscious patients Under drugs effect Under drugs effect Shying patients Shying patients Emergency situation Emergency situation

In Emergency Fast the procedure but do not ignore it Fast the procedure but do not ignore it In case of emergency, obtain information from patient and/or bystanders In case of emergency, obtain information from patient and/or bystanders

Classical history taking

Personal data Personal data Name: Name: Full, accurate Full, accurate Communicate with patient Communicate with patient Medico-legal aspects Medico-legal aspects Age: Age: Date of birth is better Date of birth is better Growth and development is noted Growth and development is noted Certain diseases correlated with age Certain diseases correlated with age Management techniques according to age Management techniques according to age

Sex: Some diseases shows sex predilection Ethics & religious consideration Marital status: Infertility, pregnant… Contacts: Address: endemic diseases, follow up visits Phone Nearest kin Personal data Personal data

Occupation: Socio economic status Race: Some certain diseases Religious: Certain considerations Date & type of admission Hospital number Personal data Personal data

Chief Complaint First symptoms that caused patient to seek medical advice First symptoms that caused patient to seek medical advice Often: Often: Pain Pain Bleeding Bleeding Abnormal function Abnormal function Observation of a lump Observation of a lump

Many complaints Always record patient’s own words In order of severity In chronological order Present History Def.: Details of symptoms & their progress Should be well organized, clear, detailed

It is important to get right back to the beginning of the problem

Present History Etiology (predisposing factors) Classical course of disease Any complications Loco-regional effect Systemic effect

Present history Negative information should be included if they contribute to the diagnosis or help exclude other possibilities Negative information should be included if they contribute to the diagnosis or help exclude other possibilities

Past & medical history

Allergy & anemia Allergy & anemia Bleeding disorders Bleeding disorders Cardio respiratory disorders Cardio respiratory disorders Drug history Drug history Endocrine disorders Endocrine disorders Fits & faints Fits & faints Gastrointestinal disorders Gastrointestinal disorders Hospital admissions & surgeries Hospital admissions & surgeries Infections Infections Jaundice & hepatic disease Jaundice & hepatic disease Kidney Kidney

Ask about health or cause of death of patient’s parents, grandparents, brothers and sisters Previous similar illnesses in the family Potential for hereditary diseases Family history

Reproductive history Infertility of both sexes Infertility of both sexes Gynecological causes of abdominal pain Gynecological causes of abdominal pain Pregnancy & lactation Pregnancy & lactation Also ask about: Also ask about: Contraceptive use Contraceptive use Venereal disease Venereal disease

Habits Smoker Smoker Athletics Athletics Appetite Appetite Alcohol Alcohol Coffee Coffee Sexual Sexual

Sensitive Topics Alcohol or drug abuse Alcohol or drug abuse Physical abuse or violence Physical abuse or violence Sexual issues Sexual issues Psychiatric problems Psychiatric problems

Sensitive Questions Guidelines Respect patient privacy Respect patient privacy Be direct and firm Be direct and firm Avoid confrontation Avoid confrontation Be nonjudgmental Be nonjudgmental Use appropriate language Use appropriate language Document carefully Document carefully Use patient’s words as possible Use patient’s words as possible

Special Challenges Silence # overly talkative patients Silence # overly talkative patients Patients with multiple symptoms Patients with multiple symptoms Anxious patients Anxious patients Anger and hostility Anger and hostility Crying & depression Crying & depression Confusing behavior or histories Confusing behavior or histories Limited intelligence Limited intelligence Developmental disabilities Developmental disabilities

Barriers to Communication May result from: May result from: Social or cultural differences Social or cultural differences Sight, speech, or hearing impairments Sight, speech, or hearing impairments Attempt to find assistance to aid in communication Attempt to find assistance to aid in communication

Patient encourages Let patient continue talking FACILITATION FACILITATION “Tell me more about it” “ Please go on” “I’m interested to hear about it “ Rocking: “Yes, Uh huh, umm, I see” Rocking: “Yes, Uh huh, umm, I see” Repeating: ”It usually happens at night?” Repeating: ”It usually happens at night?”

Confirmation Clarifying Ex: “What do you mean by fretful?” “Do you mean this.... ?” " خاطبوا الناس على قــــــدرعقولهم"

Explain to the patients what is going on Explain to the patients what is going on Encourage patient to ask questions Encourage patient to ask questions Next plain Next plain Thank the patients Thank the patients Date & signature Date & signature Finally

Do not False quick diagnosis False quick diagnosis Malignancy Malignancy Debilitating disease Debilitating disease False reassurance False reassurance May be tempting May be tempting Avoid early assurance or “over reassurance” Avoid early assurance or “over reassurance” Unless it can be provided with confidence Unless it can be provided with confidence

Thank you….! Thank you….! Any Questions