Taking a History

Taking a history From Patients • Presenting Complaint o History of Presenting Complaint ▪ Cardinal features ▪ Previous episodes and treatment ▪ Current treatment ▪ Systems review – ‘red flags’ e.g. chest pain • Past Medical History o Previous illnesses o Previous hospitalisations o Previous doctors o Previous surgeries o Allergies and drug reactions o Medications (past, present, recent changes) 🡪 over the counter, herbal supplements, vitamins, oral contraceptives • Social history o Household members 🡪 does the patient have a support system? o Occupation/education o Recent travel o Alcohol, smoking, other drugs • Preventative health • Family history Biopsychosocial model • Biopsychosocial model is broad view that attributes disease causation or disease outcome to intricate, variable interaction of: o Biological factors (genetic, biochemical) o Psychological factors (mood, personality, behaviour) o Social factors (cultural, familial, socioeconomic, medical) • Biomedical model: attributes disease to roughly only biological factors e.g. viruses, genes, somatic abnormalities Taking a history checklist (must balance with time management and distractions) • Preparing for the consultation • Connecting with the patient 🡪 building rapport Building • Identifying the patient’s agenda • Taking a relevant history • Examining the patient • Managing uncertainty • Explaining the problem • Forming a partnership in management • Following up and safety netting 3 History vs. consult • Objectives of history: o First step in making a diagnosis o Direct the physical exam and investigations o Listening and observing patient • Objectives of consultation: o Determine reason(s) for consultation o Achieve a good therapeutic outcome for patient o Develop strong doctor patient relationship Issues that may arise • No diagnosis • History is unclear or patient has a hidden agenda • There are multiple presenting complaints that may or may not be relevant to the diagnosis • Patient doesn’t accept the management plan Helman Folk Model (1981) – ‘disease vs. illness in general practise’ Pendleton et al (1984, 2003) – the consultation 1. Define the reasons for the patient’s attendance 2. Consider other problems (risk factors etc.) 3. Identifying an appropriate solution to each problem 4. Achieve a shared understanding of the problems 5. Involve the patient in the management and encourage the patient to take responsibility 6. Use time and resources appropriately 7. Establish or maintain the doctor patient relationship 4 Key consultation skills • Rapport • Listening • Questioning style • Clarification • Facilitation • Confrontation Verbal • Conversational approach: o ‘How have things been going since I last saw you?’ o ‘It’s been...weeks since I last saw you, what has been happening since then?’ • Open ended questions: o ‘Tell me about the pain’ o Allows patient to take temporary control of the consult • Move on to direct questioning: o ‘Where is the pain?’ • Avoiding medical jargon: o ‘Have you been experiencing angina recently?’ 🡪 ‘Have you had any chest pain recently?’ • Patient Centred Approach: ICE = Ideas, concerns, expectations • Documenting accurately (Medicolegal) Nonverbal • Observation of non-verbal cues from patient • Bedside manner o Primum non noncere – ‘first do no harm’ o Putting patient at ease e.g. non-hurried • Avoiding barrier-type signals • Maintaining eye-contact • Active listening: listen to message within words o ‘Doc I got a bunch of puffers from the hospital when I got discharged but I don’t know if they will help my breathing’ 🡪 poor explanation, mistrust, previous adverse events, inadequate understanding • Silence is golden – letting the patient speak