130909L - STRUCTURE OF THE MEDICAL HISTORY AND LISTENING SKILLS

Lecture for 3^rd Year Medical Students Faculty of Medicine King Fahad Medical City on September 9, 2-2013 by Professor Omar Hasan Kasule Sr.

AIM:

To learn about the basic components of a medical history and gain an understanding of the role of active listening in obtaining an accurate history.

ACTIVITIES/LEARNING OBJECTIVES/LEARNING OUTCOMES

1. List major sections of a general medical history and explain the components of each section

2. Define, describe, and demonstrate active listening skills in a patient interview

BACKGROUND READING

·         Professor Omar Hasan Kasule Sr. Diagnosis: History, Examination and Investigation

·         Professor Omar Hasan Kasule Sr. History taking

SESSION AGENDA

·         Three phases of the medical interview: (2 min)

·         Components of a medical interview regarding a specific problem (3 min)

·         Question styles (5 min)

·         Ethico-legal issues in history taking (5 min)

·         Tips on history taking (5 min)

·         Major sections of a general medical history (15 min)

·         Practicing history taking (30 min)

·         Active listening (15 min)

·         Practicing active listening (30 min)

THREE PHASES OF THE MEDICAL INTERVIEW:

·         Opening

·         Exploring and focusing

·         Closing (p. 11 Clark and Kumar)

COMPONENTS OF A MEDICAL INTERVIEW REGARDING A SPECIFIC PROBLEM 1

·         Nature of the key problem(s),

·         Clarification of the problem(s),

·         Date and time of onset,

·         Development over time,

·         Precipitating factors,

COMPONENTS OF A MEDICAL INTERVIEW REGARDING A SPECIFIC PROBLEM 2

·         Help given to date,

·         Impact of the problem on patient’s life,

·         Availability of support,

·         Patient’s ideas and fears,

·         Patient’s attitude,

·         Screening question (p. 12 clark and kumar)

QUESTION STYLES:

·         Open style eg what bought you to see me today?

·         Closed question eg what date exactly did the headache start?’ (p. 12 Clark and Kumar)

ETHICO-LEGAL ISSUES IN HISTORY TAKING

·         History taking is also an opportunity for discovery of legal complications such as foster relations that prohibit marriage, defective marriages concluded during ‘iddat.

·         In complicated medical conditions, history taking may be an opportunity for discussing costs of medical care with the patient.

·         The physician taking history may face a major ethical dilemma when in the course of taking history, the patient volunteers information about a criminal action that should be prosecuted. If the physician keeps the information to himself, he is not fulfilling the duty required of him as a citizen to report crime to the authorities.

TIPS ON HISTORY TAKING 1

·         Accurate history depends on the honesty and memory of the patient. Patients may not want to reveal some information that they consider embarrassing or that they mistakenly consider irrelevant to the presenting disease condition. Patients may forget some information or confuse it.

·         The interviewer must be tactful and sensitive in probing for relevant information and may have to adopt various strategies to help the patient’s memory.

TIPS ON HISTORY TAKING 2

·         Sometimes the interviewer may just have to keep quiet and listen actively as the patient talks to be able to pick up useful clues.

·         Interrupting patients is a frequent problem of interviewers who pressed for time would like to keep the interview as short as possible.

·         Patients with underlying emotional problems may only verbalize physical symptoms and it requires tact and establishment of rapport to get them to talk about their inner worries and feelings.

MAJOR SECTIONS OF A GENERAL MEDICAL HISTORY  1

·         Demographic/basic info about the patient

·         History of the presenting illness/complaints or Description of the presenting problem: Account of the presenting illness covers recent changes in health status, associated triggering factors, and all changes that have occurred from the start until presentation to the physician.

·         Risk factors for illness:

·         Background history: 

·         Systems review: History taking is completed by a thorough review of the organ systems. The patient is asked specific questions about symptoms in each system that may have relevance to the presenting complaint.

MAJOR SECTIONS OF A GENERAL MEDICAL HISTORY 2: Past Medical History

·         Past medical history covers health status and disease experiences as back as can be remembered. It includes medical, surgical, and psychiatric conditions.

·         Both severe illnesses requiring hospitalization and less severe ones treated symptomatically or not treated at all need to be recorded if they have relevance to the presenting illness.

·         The interviewer must have an extensive knowledge of disease epidemiology and disease pathophysiology to know what relevant questions to ask.

MAJOR SECTIONS OF A GENERAL MEDICAL HISTORY 3: Family, social history, and occupational history

• Family history elicits information about diseases in immediate family members because the presenting illness may have a familial hereditary basis or an environmental basis in the domicile of the patient.

·         Social history: Social history elicits information about social factors that are relevant to disease such as marital status, education, lifestyle (eg alcohol, drugs, smoking), and beliefs.

·         Occupational and environmental exposures should be documented for a long time before the presenting illness because for chronic diseases the causative agent may act years before the presenting illness.

DEMOGRAPHIC/BASIC INFO ABOUT THE PATIENT

·         Preferred name and title, 

·         Age,

·         Gender,

·         Ethnicity,

·         Residence/address

·         Occupation

·         Marital status

·         General condition: appearance and behavior.

HISTORY OF THE PRESENTING ILLNESS/COMPLAINTS OR DESCRIPTION OF THE PRESENTING PROBLEM

·         What: problem brought you to the hospital? What does it feel like?, what brings it on?, what else?

·         Where?,: show me where it is

·         When?,: when did it start?, when does it occur? How often? How long for?

·         How?, : how bad is it? How is it increased? How is it decreased?

·         Why? : why do you think caused it?

·         Who?: who is affected by it (Lloyd and Bor p.30)

RISK FACTORS FOR ILLNESS:

·         Based on symptoms and general medical knowledge,

·         Must include common risk factors like smoking, food, foreign travel,

·         Previous surgical and medical treatment, injuries.

SYSTEMS REVIEW 1: CARDIOVASCULAR

·         cough/sputum

·         shortness of breath

·         wheeze

·         chest pain

·         palpitations

·         ankle swelling

SYSTEMS REVIEW 2: GASTRO INTESTINAL.

·         Appetite

·         Weight change

·         Difficulty swallowing

·         Heartburn

·         Nausea/vomiting

·         Abdominal pain

·         Abdominal swelling

·         Bowel: frequency/consistency/rectal bleeding

SYSTEMS REVIEW 3 : UROGENITAL.

·         Dysuria

·         Frequency,

·         Nocturia,

·         Hematuria,

·         Testicular pain/swelling,

·         Problem urinating,

·         Menstrual details,

·         Obstetric history,

·         Contraception)

·          

SYSTEMS REVIEW 4:  NERVOUS.

·         Headaches,

·         Faints,

·         Fits,

·         Consciousness,

·         Numbness/tingling,

·         Eye sight,

·         Hearing,

·         Speech,

·         Mood,

·         Memory,

·         Concentration,

·         Weakness/wasting limbs 2.

SYSTEMS REVIEW 5: ENDOCRINE

·         Polydipsia

·         Polyuria,

·         Hot/cold intolerance,

·         Hair change

PAST MEDICAL HISTORY

·         Previous general health

·         Previous illnesses,

·         Admission to hospitals,

·         Operations,

·         Accidents and injuries,

·         Pregnancies),

FAMILY HISTORY

·         Genetics,

·         Impact of illness on family,

SOCIAL HISTORY

·         Family structure

·         Lifestyle

·         Occupation

·         Smoking

·         Drinking

·         Drug use

·         Sources of stress

PRACTICING HEADACHE HISTORY

Action	Done very well (2)	Done average(1)	Not done(0)	Comment
Start (self introduction, rapport, eye contact, consent)
Open question of why the patient came to see doctor
What questions (character of the pain, severity)
Where questions (site and radiation)
When questions (time of onset, duration, frequency)
Why questions (? Cause, precipitating factors, relieving factors)
How questions (how bad is it?
Who questions (who is affected?)
Respond to patient’s cues
Summary for the patient
Ask for feedback
Thanking the patient

PRACTICING TAKING ABDOMINAL PAIN

Action	Done very well (2)	Done average(1)	Not done(0)	Comment
Start (self introduction, rapport, eye contact, consent)
Open question of why the patient came to see doctor
What questions (character of the pain, severity)
Where questions (site and radiation)
When questions (time of onset, duration, frequency)
Why questions (? Cause, precipitating factors, relieving factors)
How questions (how bad is it?
Who questions (who is affected?)
Respond to patient’s cues
Summary for the patient
Ask for feedback
Thanking the patient

ACTIVE LISTENING

• Listening
• Active listening: Definition:
• Active listening: Posture:
• Active listening: Feedback by Body language:
• Active listening: Oral feedback:
• Demonstration of active listening:

LISTENING

·         Listening can be active (with feedback)

·         Listening can be passive (no response)

·         Barriers to effective listening are weak extrinsic motivation, personal constraints, environmental constraints, and poor timing of the message.

ACTIVE LISTENING: DEFINITION:

·         Concentrate,

·         Pay attention,

·         Encourage,

·         Understand.

ACTIVE LISTENING: POSTURE:

·         Sit  at eye level,

·         Face patient squarely,

·         Maintain eye contact except for female patients,

·         Lean slightly forward,

·         Open posture do not cross arms and legs,

·         Sit at an appropriate distance,

·         Do not fidget.

ACTIVE LISTENING: FEEDBACK BY BODY LANGUAGE:

·         Respond appropriately (with facial, eye, and hand movements, head movements such as nodding )

·         Avoid negative body language according to local culture (nodding up down vsside ways, pointing the figure, making a fist, clasping fingures, touching a patient of the same gender), 

·         Smile to approve but do not frown to disapprove,

ACTIVE LISTENING: ORAL FEEDBACK:

·         Encourage/show you are listening (hm, tafadhal, go on, yes, hulw,),

·         Avoid meaningless verbal feedback (ok, wah, oh). S

·         How concern/empathy with difficult situations.

DEMONSTRATION OF ACTIVE LISTENING:

·         Instructor interview of a simulated patient on presenting illness.

·         Students interviewing one anotheron presenting illness.

·         Use of a check list by both the interviewer, the interviewee, and the rest of the class

·         Feedback: by the interviewer about what he did/didn’y do well,

·         Feedback by other students observing the interview,

·         Llisting of successful techniques

·         Listing of common difficulties and how they were handled,

ACTIVE LISTENING CHECK LIST

Action	Done very well (2)	Done average(1)	Not done(0)	Comment
interviewer giving full name and title/position
interviewer explaining what he wants to do,
interviewer assurance of confidentiality
interviewer asking for permission and receiving or non verbal agreement,
interviewer thanking the patient for consent to be interviewed,
use of open questions and letting the patient talk,
not interrupting or directing the patient
interviewer not disagreeing with the patient or suspecting him of lying
checking to make sure the patient is confortable
appropriate us of body language
verbal feedback,
dealing with a talkative or off point patient
terminating by summarizing the interview and giving feedback to the patient
asking the patient If he has any questions
thanking the patient for his time