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Chapter 1 The History and Interviewing Process The history and physical examination begin, and are at the heart of, the diagnostic and treatment process. The techniques you will learn are orderly but are not rigid. To prevent misinterpretations and misperceptions, you must make every effort to sense the world of the patient as that patient sees it. Goals Discover information leading to diagnosis and management. Provide information about diagnosis. Negotiate and share in health care management. Counsel about disease prevention. The Ethical Context Autonomy Patient’s self-determination Beneficence Do good for the patient. Nonmaleficence Do no harm to the patient. The Ethical Context (Cont.) Utilitarianism Appropriate use of resources for the greater good Fairness and justice Equitable treatment of all Deontologic imperatives Care delivered according to traditions and in cultural contexts Effective Communication Factors That Enhance Communication Establishing a positive patient relationship depends on communication built on: Courtesy Comfort Connection Confirmation Confidentiality Enhancing Patient Responses Open-ended question Allows patient discretion about the extent of an answer Direct question Seeks specific information Leading question May limit the information provided to what the patient thinks you want to know Enhancing Patient Responses (Cont.) If the patient does not understand what you are asking, remember to: Facilitate: Encourage your patient to say more. Reflect: Repeat what you have heard. Clarify: Ask “What do you mean?” Empathize: Show understanding and acceptance. Confront: Address disturbing patient behavior. Interpret: Repeat what you have heard to confirm the patient’s meaning. Communication Tensions Curiosity about you Anxiety Silence Depression Crying Physical intimacy Emotional intimacy Seduction Anger Avoidance Financial considerations Language The History Taking the history usually begins your relationship with the patient. Setting for the Interview Comfort for all involved Removal of physical barriers Good lighting Privacy Relative quiet Unobtrusive access to clock The Patient History Identify those matters the patient defines as problems. Establish a sense of the patient’s reliability. Consider the potential for intentional or unintentional suppression or underreporting of information. Remain in a constant state of subjective evaluation of the patient’s words and behaviors. Adapt to the modifications that age, pregnancy, and physical and emotional handicaps mandate. Structure of the History The identifiers: name, date, time, age, gender, race, occupation, and referral source Chief concern History of present illness (HPI) Past medical history (PMH) Family history (FH) Personal and social history (SH) Review of systems (ROS) Building the History Introduce yourself. Address patient properly. Be courteous. Make eye contact. Do not overtire patient. Do not be judgmental. Be flexible. Building the History (Cont.) Avoid medical jargon. Take notes sparingly. Avoid leading questions. Start with general concerns, then move to specific descriptions. Clarify responses with where, when, what, how, and why questions. Verify and summarize what you have heard. Approaching Sensitive Issues Use language that is understandable. Do not apologize for broaching the issue. Ensure privacy. Be direct and firm. Do not preach. Do not push too hard. Sensitive Issues Alcohol and drug use Domestic violence Spirituality Sexuality Alcohol The CAGE questionnaire was developed in 1984 by Dr. John Ewing, and it includes four interview questions designed to help diagnose alcoholism. The acronym “CAGE” helps practitioners quickly recall the main concepts of the four questions (Cutting down, Annoyance by criticism, Guilty feeling, Eye-openers). Probing questions may be asked as follow-up questions to the CAGE questionnaire. Alcohol (Cont.) TACE questionnaire T–How many drinks does it Take to make you feel high? A–Have people Annoyed you by criticizing your drinking? C–Have you felt you ought to Cut down on your drinking? E–Have you ever had an Eye-opener drink first thing in the morning to steady your nerves or get rid of a hangover? Alcohol (Cont.) The CRAFFT questionnaire was developed in 2002 as a screening tool for alcohol and substance abuse in adolescents. The CRAFFT acronym helps practitioners remember the main concepts of the six questions: Car, Relax, Alone, Forget, Friends, Trouble. Screening vs. Assessment There is a difference between a screening and an assessment interview. The goal of screening is to find out if a problem exists. This is particularly true of CAGE, CRAFFT, and TACE questionnaires. They are effective, but they are only the start, and assessment goes on from there. Domestic Violence About 94% of reported victims of domestic abuse are women. They come from every ethnic and socioeconomic group. Domestic Violence (Cont.) Three questions comprise a brief screening instrument to detect partner violence. Have you ever been hit, kicked, punched, or otherwise hurt by someone within the past year? Do you feel safe in your current relationship? Is there a partner from a previous relationship who is making you feel unsafe now? Domestic Violence: HITS Verbal abuse is as intense a problem as physical violence. The wording of the question is “In the last year how often did your partner: Hurt you physically?” Insult or talk down to you?” Threaten you with physical harm?” Scream or curse at you?” Spirituality Many patients want attention paid to spirituality. Faith can be a key factor in the success of a management plan. Some patients may prefer that you not breach the subject. The acronym FICA can be used as an approach. Spirituality: FICA Faith, belief, meaning What is your spiritual heritage? What writings are important to you? Do these beliefs help you cope with stress? Importance and influence How have these beliefs influenced how you handle stress? To what extent? Community Do you belong to a formal spiritual or religious community? Address/action in care How do your religious beliefs affect your health care decisions? How would you like me to support you in this regard when your health is involved? Sexuality The sexual orientation of a patient must be known if appropriate continuity of care is to be offered. About 10% of the persons you serve are likely to be other than heterosexual. Trust can be better achieved if questions are “gender neutral.” Tell me about your living situation. Are you sexually active? In what way? Outline of the History Chief concern (CC) or the reason for seeking care History of present illness or problem (HPI) Past medical history (PMH) Family history (FH) Personal and social history (PSH) Review of systems (ROS) Chief Concern Note all significant complaints. Seek answer to the question “What underlying problems or symptoms brought you here?” Determine the duration of the current illness by asking “How long has this problem been present?” Or “When did these symptoms begin?” Note age, gender, marital status, occupation, and previous hospital admissions. History of Present Illness: Explore the following Chronology of events Health state before present problem First symptoms Exposure to infection or toxic agents Typical attack Illness impact on lifestyle Stability of problem Immediate reason for visit Review of involved systems Medications list Complementary or alternative therapies Chronology review Problem list Past Medical History: Explore the following Past medications Allergies (drugs, environment, food) Past transfusions Recent screening tests Emotional status General health Childhood illnesses Major adult illnesses Immunizations Surgery Serious injuries and resulting disability Functional ability limitations Family History: Explore the following Blood relatives with illness similar to the patient’s illness Blood relatives with history of major disease Determine if any cancers have been multiple, bilateral, occurred more than once in the family, and occurred at a young age (less than 50 years). Note the age and outcome of any illness. Family History: Explore the following (Cont.) Note the ethnic and racial background of the family. Note the age and health of the patient’s spouse/partner or the child’s parents. A pedigree diagram helps illustrate the family members with a disorder. There should be at least three generations for the pedigree. Personal and Social History: Explore the following Personal status Habits Sexual history Home conditions Occupation Environment Military record Religious preference Access to care Review of Systems: Explore the following General constitutional symptoms Skin, hair, and nails Head and neck Lymph nodes Chest and lungs Breasts Heart and blood vessels Peripheral vascular Hematologic Gastrointestinal Diet Review of Systems: Explore the following (Cont.) Endocrine Female Male Genitourinary Musculoskeletal Neurologic Psychiatric Concluding questions General Constitutional Symptoms Fever Chills Malaise Fatigability Night sweats Sleep patterns Weight Average Preferred Present Change Skin, Hair, and Nails Rash, eruption, itching Pigmentation or texture change Excessive sweating Abnormal nail or hair growth Head and Neck: General Headaches Dizziness Syncope Head injuries Loss of consciousness Head and Neck: Eyes Acuity Blurring Diplopia Photophobia Pain Vision changes Glaucoma Eye medications Trauma Head and Neck: Ears Hearing loss Pain Discharge Tinnitus Vertigo Head and Neck: Nose Sense of smell Colds Obstruction Epistaxis Postnasal discharge Sinus pain Head and Neck: Throat and Mouth Hoarseness or change in voice Sore throats Bleeding gums Tooth abscesses, extractions Soreness or ulcers of tongue/mucosa Taste changes Lymph Nodes Enlargement Tenderness Suppuration Chest and Lungs Pain Dyspnea Cyanosis Wheezing Cough Sputum Hemoptysis Night sweats Exposure to tuberculosis Last chest radiograph Breasts Development Pain Tenderness Discharge Lumps Galactorrhea Mammograms Screening Diagnostic Self-awareness Self-examination Heart and Blood Vessels Chest pain Palpitations Dyspnea Orthopnea Edema Claudication Hypertension Previous myocardial infarction Exercise tolerance Date of last electrocardiogram Other cardiac tests Peripheral Vascular Claudication Frequency Severity Tendency to bruise or bleed Thromboses Thrombophlebitis Hematologic Anemia Blood cell abnormalities Past transfusions Gastrointestinal Appetite Digestion Food intolerances Dysphagia Heartburn Nausea/vomiting Hematemesis Regularity of bowels Constipation Diarrhea Change in stools Hemorrhoids Jaundice Previous imaging studies Diet Appetite Likes and dislikes Diet restrictions, cultural constraints Vitamins and other supplements Caffeine Dietary recall Endocrine: General Thyroid enlargement or tenderness Heat/cold intolerance Weight change Diabetes Polydipsia Polyuria Changes in facial or body hair Increased hat or glove size Skin striae Endocrine: Female and Male Female: Menses Discharge, itching Last Pap smear Libido, intercourse Birth control Infertility, pregnancy Menopause Male: Puberty onset Erections Emissions Testicular pain Libido Infertility Genitourinary Sexually transmitted infections Dysuria Pain Urgency Frequency Nocturia Hematuria Polyuria Hesitancy Dribbling Loss in force of stream Passage of stone Edema of face Stress incontinence Hernias Musculoskeletal Joint stiffness, pain Restriction of motion Swelling, redness, heat Bony deformity Neurologic Syncope Seizures Weakness or paralysis Abnormalities of sensation or coordination Tremors Loss of memory Psychiatric Depression Mood changes Difficulty concentrating Nervousness Tension Suicidal thoughts Irritability Sleep disturbances Concluding History Questions Is there anything else that you think would be important for me to know? What problem concerns you most? What do you think is the matter with you? What worries you the most about how you are feeling? Adaptations for Age, Gender, and Handicaps Children Pay attention to them (place equal emphasis on the child and on the accompanying adult). Glean clues about family dynamics. Be sensitive to their needs. Play with them. Children: Explore following issues Mother’s gestational history, pregnancy, and birth Child’s neonatal period, feeding, and developmental milestones Child’s school adjustment, habits, and home conditions Review systems for child-specific conditions. Adolescents Respect need for confidentiality. Respect impending adult status. Do not force conversation. Establish an alliance. Be flexible in approach. Adolescents (Cont.) Factors impacting history taking Self-esteem, acceptance by peers, tension with parents Cover issues of special concern. (Hint: Use mnemonic HEEADSSS or PACES to zero in on issues.) Adolescents: Explore following issues HEEADSSS Home environment Education Eating Activities, affect, ambitions, anger Drugs Sexuality Suicide/depression Safety PACES Parents, peers Accidents, alcohol/drugs Cigarettes Emotional issues School, sexuality Pregnant Women Consider health needs of mother and fetus. Explore effects of pregnancy on health status. Use interview as time for teaching health care practices. Pregnant Women: Explore following issues Current pregnancy and obstetric history Exposure to environmental/occupational hazards Family genetic conditions/congenital abnormalities Personal and social issues of pregnancy and parenting Reproductive, cardiovascular, endocrine, respiratory system focus Risk factors that threaten mother and fetus Older Adults Watch for age-related changes that may impede interview. Sensory loss, visual impairment, cognitive impairment, or memory loss Draw on person’s cumulative lifetime experience, wisdom, and perspective. Older Adults: Explore following issues Multiple overlapping health problems Chronic symptoms Complete drug assessment Assessment of functional capacity Patients With Disabilities Adapt interview approach to fit needs. Involve the patient to the limit of emotional, mental, and physical abilities. Family members are often available to make the patient more comfortable and provide further information. Types of Histories A “complete” history is not always necessary. You may know the patient well and be considering the same problem over time. Adjust your approach to the need at the moment. Types of Histories (Cont.) Complete history Most often recorded the first time you see the patient Inventory history Related to but does not replace the complete history Touches on major points without complete detail Entire history will be completed in more than one session Types of Histories (Cont.) Problem (or focused) history Taken when a problem is acute so that only the need of the moment is given full attention Interim history Designed to chronicle events that have occurred since your last meeting with the patient Substance determined by nature of problem and need of the moment Should always be complemented by the patient’s previous medical record The Next Step Physical examination The laying on of hands Question 1 A health history that is designed to chronicle events that have occurred since the patient’s last visit is called a: A. Interim history B. Problem history C. Inventory history D. Complete history Question 2 The CAGE screening test for alcoholism is suggestive of the disease if there are two positive responses. What does the A stand for? A. Annoyance by criticism B. Alcohol in the AM C. Abnormal drinking habits D. Alert after excessive alcohol Question 3 The chief concern: A. Requires step-by-step evaluation of the circumstances B. Explores the patient’s overall health C. Is a statement about why the patient is seeking care D. Is a detailed inquiry of possible concerns Question 4 The history of present illness includes which of the following: A. Unique concerns that explain the prevention needed B. Presence or absence of health-related issues C. Chronologic ordering of events D. General health and strength Question 5 Which of the following is initially appropriate in the management of a patient’s diagnosed problem? A. Inform the patient of the treatment plan. B. Give the patient detailed written instructions regarding the treatment plan. C. Inform the patient that the plan has been tailored to his or her needs. D. Inform the patient of treatment options and possible results. Question 6 Which question would be considered a “leading question”? A. “What do you think is causing your headaches?” B. “You don’t get headaches often, do you?” C. “On a scale of 1 to 10, how would you rate the severity of your headaches?” D. “At what time of the day are your headaches the most severe?”