Good morning, I am Tamás FENYVESI

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Good morning, I am Tamás FENYVESI

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The medical interview

Anamnesis

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αναμνησις The main purpose: to gather all basic information patient’s illness pertinent to the , and the patient’s adaptation to illness.

Tamás Fenyvesi 3

What is spoken of as a ‘clinical picture’ is not just a photograph of a man sick in bed; it is an impressionistic painting of the patient surrounded by his home, his work, his relations, his friends, his joys, sorrows, hopes,and fears. (Peabody, 1927) 4

What the patient thinks is happening, what kind of impact does the illnnes bear on work, family, financial situation.

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Communication is the key to a successful interview.

Ask questions freely .

Permit the patient to tell his/her story in his/her own words.

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If the story is very vague use direct questions: “ How …” “ Where …” “ When …” is better than “ Why …” Patients like to respond to questions in a way that will satisfy the doctor

!

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Treat the patient with respect, take care not to contradict the pt.

You should refrain from trying to impose your own moral standards on the pt.

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Remember the „ rule of five vowels ” A udition: listen carefully E valuation: sorting out of relevant I nquiry: additional relevant problems question in the O bservation:notice …...nonverbal

communication (b.l.) U nderstanding: the patient’s concerns

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Beware!!!

The management may have a different approach

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The medical interview is the basis of the

good doctor patient relationship

Flexible - spontaneous - not interrogating It is a powerful diagnostic tool.

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Conducting an interview

1.

Greeting and introduction

“ Mr. Smith, I’m John Taylor a medical student.

I’ve been asked to interview and examine you.

” “Dear” or “Grandpa” are not to be used.

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2.

Start with a very general question e.g.: “ What problem hospital?” “ open-ended ” has brought you to the Do not start with reading of previous medical reports!!

Persue the problems with open-ended questions: more specific “Tell me more about your chest pain.”

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3.

Direct questions to specific facts learned during the open ended questions:

where?

when?

how?

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\ Symptoms

(what the patient feels, e.g. pain)

are considered in the classic „seven dimensions”

:

1.Bodily location :

“ Where in your anywhere else?” back?” “Do you feel it

2.Quality:

“What does it feel like?” “Was it sharp, dull or aching?” 16

3.Quantity:

“How many pills do you use?” “What do you mean by a lot?”

4.Chronology

: “When did you first notice it?” “How long did it last?” “Have you had the pain since that time?” 17

5.Setting:

“Does it ever occur at rest?” “Do you ever get the pain when you are emotionally upset?”

6.Provocative

:

“What seems to bring on the pain?”

7.Palliative

: “What do you do to make it better?” 18

Question types to be

1.Yes or no

avoided

question in general problems : ” is your work satisfying?” The patient may want to please the doctor

2. Suggestive question

: “ Do you feel the pain in your left arm, when you get it in your chest?” 19

(avoid)

3.Why question:

They may carry tones of accusation.

“Why did you wait so long?”

4.Multiple question :

“How many brothers and sisters you have and do they have…?”

5.Medical terms in question :

“Did you have a paraparesis?” 20

Do not write extensive notes

during the interview, it distracts you from observing the pt’s facial expressions, b.l.

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Next step

Silence

- 2 minutes “What are you thinking about?” “You are saying…”

Facilitation

Verbal or non-verbal 22

Confrontation

“Why are you so silent?” “You look upset.”

Interpretation

“You seem to be quite happy about that.” 23

Support

“I understand.”

Reassurance

“You are improving steadily.”

Empathy

It is understanding, not an emotional state of sympathy.

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Be aware of the patient who asks

, “I have a friend with…., what do you think about…..?” The question is probably related to

the pt’s own concerns

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“ The doctor may also learn more about the illness from the way the patient tells the story than from the story itself” James B. Herrick 1861-1954 26

Each patient brings a different

• • • • • • • • •

challenge :

silent overtalkative seductive angry insatiable ingratiating aggressive help rejecting demanding 27

Format of the history

Source and reliability Patient or else?

‘hetero-anamnesis’ Chief complaint The patient’s brief statement why he/she sought medical attention.

History of present illness What, when, how, where, which, who and why 28

Past medical history

General state of health Past illnesses Hospitalizations Injuries Surgery Allergies Immunisations 29

Substance abuse* Diet Sleep patterns Current medication *In Hungary the most common substance abuse is alcoholism and smoking!! You must ask the question on smoking.

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The best questionnaire as a tool for disclosing alcoholism is „

CAGE ”:

“Have you ever felt the need to

c

ut down on your drinking?” “Have people

a

nnoyed you by criticising your drinking?” “Have you ever felt your drinking?”

g

uilty about “Have you ever taken a morning

e

ye opener” to steady your nerves?” 32

Occupational and environmental history Exposure to disease-producing substances More than just listing the jobs duration protective devices?

medical screening?

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Biographical information Family history Information about the health of the entire family diseases in the family 34

Genetic implication hypertension diabetes MI Psychosocial history Education, life style, sexual history (a very sensitive problem, depends very much on the gender of doctor and patient) 35

Review of systems

It Σ all the many symptoms that may have been overlooked in the history of present illness and in the past medical history.

It is best organized from the head down to the extremities.

These questions should be asked in a way that the patient could answer just “yes” or “no”.

We need further questioning in case of “yes”.

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At this phase it is best to have a checklist.

Customize clinical narrative to

electronic medical record (EMC)

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An informative example: Cardiac High blood pressure Pain Palpitations Shortness of breath with exertion Shortness of breath when lying flat History of heart attack Rheumatic fever Heart murmur Last ECG 38

Other ? for heart function Fatigue Edema Cyanosis Hemoptysis (caughing up blood) 39

Chest pain “Where is the pain?” “Does it radiate?” “Where?” “For how long have you had the pain?” “Do you have recurrent episodes of pain?” 40

“What is the duration?” “How often do you get the pain?” “What do you do to make it better?” “What makes it worse? Breathing? Lying flat?

moving your arms or neck?” “How would you describe the pain?” Let the patient describe it! And then ask: “burning?… pressing?… crushing?… dull?… aching?… throbbing sharp?… constricting?… sticking?” 41

“Does the pain occur at rest? … with exertion?

… after eating? … when moving your arms?

… with emotional strain?… during sex?” “Is the pain associated with shortness of breath?

vomiting?

… palpitations? … nausea or … coughing?... fever? … leg pain?

coughing up blood?” “When was the last episode of your chest pain?” 42

Common causes of chest pain

Cardiac Coronary artery disease Aortic valvular disease Pulmonary artery hypertension Mitral valve prolapse Pericarditis HOCM (hypertrophic obstructive cardiomyopathy) 43

Vascular Dissection of the aorta Pulmonary Embolism Pneumonia Pleuritis PTX (pneumothorax) 44

Musculosceletal Costochondritis (Tietze’s syndrome) Arthritis Muscular spasm Bone tumor Neural Herpes zoster 45

Gastrointestinal Ulcer Bowel disease Hiatal hernia (GERD) Pancreatitis Cholecystitis Emotional Anxiety Depression 46

As you notice: to put the right questions you have to know the typical symptoms of the suspected disease!!

e.g. heart failure:

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Symptoms of heart failure I.

1. Respiratory signs-

exertional breathlessness orthopnoe supine or sitting redistribution of blood volume pulmonary venous and capillary pressure paroxysmal nocturnal dyspnea-cardiac asthma 1.slow resorption of interstit fluid 2.expansion of thoracic blood volume 3.reduced adrenergic support in sleep 4.nocturnal depression of the resp. center pulmonary edema 48

Symptoms of heart failure II.

2.fatigue and weakness

hypoperfusion of the sceletal musculature hyponatremia caused by diuretics

3.nocturia

redistribution of cardiac output at night: RBF

4.liver distension

epigastrial dyscomfort This leads you to….

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Class I

NYHA Classification of HF

—

No limitation:

Ordinary physical activity does not

Class II

cause undue fatigue, dyspnea, or palpitation. —

Slight limitation of physical activity:

Such patients are comfortable at rest.Ordinary physical activity results in fatigue, palpitation

Class III

dyspnea, or angina. —

Marked limitation of physical activity:

Although patients are comfortable at rest,

Class IV

less than ordinary activity will lead to symptoms.

—

Inability to carry on any physical activity without discomfort:

Symptoms of congestive

failure

are present even at rest. With any physical activity, increased discomfort is experienced.

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Finally to end the interview tactfully (e.g.):

“ shut up, please !

”

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The accuracy may be influenced in different ways.

The history is reproducible.

not well enough 1. Different physicians ask the questions in different way, and interpret the answers differently.

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2 Patients often give frankly different answers to the very same question.

student resident (awkward situation) Careful use of essential.

consultant clear questions is 53

At this stage : review the documentation of past medical history 54

History is the key to doctor-patient relationship and to DIAGNOSIS!

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The written history is a summary of the information interview: obtained during the

Chief complaint History of present illness Past medical history Family history Psychosocial history Review of systems (not in preprinted format) 56

Problems of PC-based history taking: It may serve as a guideline not to forget anything.

Questionnaires handed to the patient is not history taking!!

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Robinson JD., Heritage J. Patient Education and Counseling 2006;60:279 58

Robinson JD., Heritage J. Patient Education and Counseling 2006;60:279 59

“ To study the phenomenon of disease without books is to sail an uncharted sea, while to study books without patients is not to go sea at all” William Osler 60

If you wish to know a bit more: go to Google Results about

4.020.000

“

medical history taking

” entries for Reached 20 08 2008 www.youtube.com/watch?v=u1x9M_S8fCw a video example 61

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“. . . For the secret of the care of the patient is in caring for the patient.” Francis Weld PEABODY, 1881-1927 63