1. History Taking: Content & Process Lao Clinical Science Family Medicine Specialist Medical Curriculum Communication Course September 18 2006 Dr. Lanice Jones & Dr. Gwen Hollaar & Dr Bob Lee

2. Outline of the Course – 2 sessions of Building an Elephant

3. 3 Parts to the Elephant Content – Easiest to Teach and Learn: what we need to know about the patient Process – a little more difficult: What questions to ask, and how to ask to get the information that we need Relationship Building: Developing the Doctor-patient relationship

4. Medical Content Patient Identification Patients Concern History of Present Illness Past Medical History Family History Social History Review of Systems Summary Problem List Plan

5. Patient Identification Name Age Address/Village

6. Patient Concern Get the list of patient concerns at the beginning of the interview

7. History of Present Illness Get the details about the main symptoms. For example: Symptom of pain Where is the pain? When does the patient have the pain? What is the Quality of the pain? What is the Quantity of the pain (how often)? Aggravate – what makes the pain worse? Alleviate – what makes the pain better? Associated Symptoms – what other symptoms are associated with this pain? Belief: What does the patient think is going on?

8. History of Present Illness To give examples of what to ask about associated symptoms Symptom: Cough Ask further questions specifically about fever, sputum, hemoptysis, weight loss, anorexia, night sweats, ***eating uncooked seafood Symptom: abdominal pain jaundice, nausea, vomiting, diarrhea, blood in the stool

9. History of Present Illness Why do we ask about what the patient thinks or believes are causing their symptoms? Helps to identify the patient’s fear Allows you to consider investigating and treating that patient’s fear Is a helpful way to develop a trusting relationship with a patient

10. Past Medical History Other medical problems the patient has or had Past hospitalizations and past surgeries Medications Allergies Pediatric: Pregnancy, Birth history, Developmental Milestones, Immunizations

11. Family History Parents History: if died, how old and what they died of Illnesses in Brothers and Sisters Illnesses in their children May include extended family members

12. Social History Smoking (how long / how often) Alcohol (how much) Any other drug use Who they live with Occupation

13. Review of Systems “Head to Toe” check-list of symptoms If it is important to the history of present illness, it belongs in there The purpose of the ‘Review of Systems’ is to identify any other problems not mentioned or missed

14. Review of Systems General: Weight loss/gain, appetite, night sweats, fatigue Head & Neck: headaches, ear or eye or throat problems, difficulty swallowing Respiratory: shortness of breath, coughing, sputum (describe sputum) Cardiac: palpitations, chest pain, ankle swelling, shortness of breath when lying down or at night

15. Gastrointestinal: abdominal pain, gas, bloating, nausea, vomiting, diarrhea, constipation, blood in the stool, jaundice Urinary: frequency, dysuria, nocturia, hesitancy, incontinence, +/- sexual dysfunction MSK: joint or limb pain, swelling, redness Neuro: loss of function, numbness or weakness

16. Patient Identification:John Doe 36 y.o. man from Pakse farmer Patient Concern: Cough & Hemoptysis History of Present Illness: 2 month history of cough Sputum contains streaks of blood Cough is worse with smoking Nothing improves the cough Patient tried antibiotics with no relief Associated symptoms: weight loss of 10 Kg, night sweats, anorexia, fatigue, no chest pain Past Medical History Medical: no past medical problems Surgery: no past surgery Allergies: none Medications: Took 10 days of cephalexin, no relief Family History: Mother finished TB Rx 2 months ago Father alive and well Other family members healthy Social History: Smokes about 8 cigarettes per day & has smoked for 16 years Drinks Beer Lao 1 or 2 per day, Lao Lao at weddings Married, 3 children Review of Systems Occasional headaches

17. Process – How to get the Patient’s Information Introduction: Introduce yourself and your role, and if you are a student, explain who your preceptor is Ask an Open Ended Question to find out the Current Concern: Open Ended Questions – can not be answered by 1 or 2 words Closed Ended – can be answered by 1 or two words: Do you have any headaches? How long have you had the chest pain?

18. Process: Use Open Ended Questions to Identify the Patient Concern What is your concern today? What is your problem today? What would you like to discuss today? What brought you to the doctor today? How can I help you today?

19. Process: Explain what you are going to do next Explain that you are going to ask more questions about the patient’s problem Explain that you are going to ask more questions about their medical problems in the past, family medical problems and about their life in general Explain that you will then examine the patient after asking the questions

20. Process: Opening Questions for History of Present Illness Examples: Can you start at the beginning, and tell me all about your _________ (headache,cough, pain) When were you last completely well? Can you tell me all about what symptoms you have had from then until now? Tell me everything about your headache.

21. Process: At the End of the History of Present Illness Give a summary, and ask if you’ve understood correctly, or you may ask if there is any more information the patient might like to add. (Some physicians do this at the very end of the history taking instead) Tell the patient that you are moving on to ask more general questions about their past medical history

22. Process: Ask the patient about Past Medical History Past Medical History Medical Surgical Medications Allergies to Medications or otherwise Family History Social History

23. System Review Give me an example of a statement that you could use to inform the patient that you are going to ask them questions to make sure there are no other health problems

24. Now you’ve got your information Give a Summary Ask if you’ve understood the information correctly Ask if there is any other information that the patient wants you to know Advise what your plan would be Check with the patient that they are in agreement with your plan

25. When the intern gives you the history after they have seen the patient, be sure it is complete Be consistent in the history that you expect from the interns They will only get better with more and more practice!