Transcript Inquiry
Inquiry Department of Gastroenterology Ren-Ji Hospital Prof. Zhi Hua Ran Inquiry It is the method that physician obtain the clinic data of patient, and further propose clinical judgment by comprehensive analysis Inquiry is the major methods of history taking It is a fundamental skill that every physician should know Basic principles Good communication skills are the foundation of excellent medical care It improves health outcomes by resolving symptoms and reducing patients’ psychological distress and anxiety The quality of patient care depends greatly on the skills of interviewing, because the relationship that a patient has with a physician is probably the most extraordinary relationship between two human beings Basic principles To gather all basic information pertinent (相关的） to the patient’s illness and the patient’s adaptation to illness An experienced interviewer considers all the aspects of the patient’s presentation and follows the leads that appear to deserve the most attention Basic principles The clinician must be keenly aware of all clues, subtle or obvious Although body language is important, the spoken word remains the central diagnostic tool in medicine The art of talking and listening continues to be the central part of the doctor-patient interaction Once all the clues from the history have been gathered, the assimilation（消化） of those clues into an ultimate diagnosis is relatively easy Basic principles Communication is the key to a successful interviews It must be able to ask questions of the patient freely These questions must always be easily understood and keyed to the medical sophistication of the patient Content of inquiry General data Chief complaint History of present illness Past history Review of systems Personal history Marital history Menstrual history Family history General data Name Age Native place Marital status Profession Data of record Reliability Sex birth place Nation Mail address Data of admission Source Chief complaint It is the patient’s brief statement explaining why he or she sought medical attention It is the answer to the question “What is the problem that brought you to the hospital?” In the written history, it is frequently a quoted statement of the patient Chief complaint It should be one or two sentences including the time periods from onset to seeing the doctor Not the diagnostic term from the doctor Chief complaint “Chest pain for the past 5 hours” “Terrible nausea and vomiting for 2 days” “Headache for the last week, on and off” History of present illness The history of the present illness refers to the recent changes in health that led the patient to seek medical attention at this time It describes the information relevant to the chief complaint It should answer the questions what, when, how, where, which, who, and why History of present illness Chronology（按年月次序的排列） is the most practical frameworks（框架） for organizing the history It enables the interviewer to comprehend（理解） the sequential development of the underlying pathologic process History of present illness In this section the doctor gathers all the necessary information, starting with the first symptoms of the present illness and following its progression to present day It is important to verify that the patient was entirely well before the earliest symptom to establish the beginning of the current illness History of present illness The character of symptoms location identity during intensity relief or provoke factors（触发因素） Time during may be lasted for years, months, days It may also be of hours or minutes (in those with acute onset) History of present illness Causes and inducing factors investigate the causes that related with onset of the disease: trauma intoxication infection inducing factors: emotion diet environment Caution the causes that recently occurred may be easily recognized by the patient hardly recognized by the patients if the causes are complicated or if the courses lasted for years History of present illness Progression including the changes in predominant symptoms or occurrence of new symptoms cirrhotic patient manifested some neurological signs, hepatic encephalopathy should be highly suspected chest pain lasted unusually and more severely than previous episodes（发作） of angina, myocardial infarction should be suspected History of present illness Accompanying symptoms it is useful in differential diagnosis e.g. patient manifested nausea, vomiting and fever, accompanied with jaundice and/or shock, acute biliary infection or acute pancreatitis should be considered History of present illness Course of diagnosis and treatment The diagnosis and treatment the patient had received in other medical institution may provide informative data The diagnosis made by others could not replace one’s diagnosis General condition during the course it may also provide some useful information Past medical history The past medical history consists of the overall assessment of the patient’s health before the present illness include a statement of childhood and adult problems Parameters including: general state of health injuries surgery immunizations diet current medications past illness hospitalizations allergies substance abuse sleep patterns alternative therapies Past medical history The patient should be asked about any prior injuries or accidents The type of injury and the data are important All hospitalization must be indicated, including admissions for medical, surgical, and psychiatric illness All surgical procedures should be specified. The type of procedure, data, hospital All allergies should be described. These include environmental, ingestible, and drug related It is important to determine the immunization history of all patients Review of systems The review of systems summarizes in terms of body systems all the symptoms that may have been overlooked in the history of the present illness or in the medical history By reviewing in an orderly manner the list of possible symptoms, the interviewer can specifically check each system and uncover additional symptoms of “unrelated” illness not yet discussed Review of systems The review of systems is best organized from the head down to the extremities Patients are told that they are going to be asked whether they have ever had a particular symptom and should answer “Yes” or “no” Review of systems Respiratory system cough: identity frequency sputum production: quantity appearance coughing up blood shortness of breath Cardiovascular system chest pain shortness of breath with exertion palpitations shortness of breath lying flat sudden shortness of breath while sleeping history of heart attack Review of systems GI system appetite excessive hunger excessive thirst nausea constipation diarrhea heartburn vomiting abdominal pain change in stool color/caliber/consistency frequency of bowel movements vomiting blood rectal bleeding black tarry stools Review of systems Urinary system frequency urgency incontinence difficulty in the starting the stream excessive urination pain on urination burning blood in the urine bed-wetting flank pain history of retention urine color urine odor Review of systems Hematological system pallor yellow skin petechia purpura ecchymosis hematoma Endocrinological system and metabolite weakness profound sweating abnormal appetite weight change Review of systems Neurologic system fainting dizziness mood changes loss of memory speech disorders general behavioral change disorientation Musculoskeletal weakness paralysis muscle stiffness limitation of movement joint pain joint stiffness arthritis gout deformities Review of systems Review of systems may involved lots of clinical diseases One has to understand the pathophysilogical meaning of these signs and symptoms In each systems, it is practical to ask several symptoms The inquire may be intensified if there is positive symptoms/signs is elicited Personal history Social experiences birth place living area and duration particularly those epidemical areas education living condition hobby Profession and working place/condition Habit smoking (amount and duration) anesthetic drug（麻醉药） Unhealthy sexual history Unhealthy sexual history: Sexually transmitted disease Marital history Marital history: single or married age of marriage heath condition of partner Menstrual history Menstrual history age of menarche (first menstrual cycle) cycles and flow lasting amount of vaginal bleeding/discharges menopause and age of menopause Format flow lasting(day) menarche last menopause cycle(day) Family history It provides information about the health of the entire family,living and dead Pay attention to possible genetic and environmental aspects of disease that might have implications for the patient Skill and methods in inquire Getting started The narrative（叙述） The closing Getting started The diagnostic process begins at the first moment of meeting One should be dressed appropriately, wearing a white coat with one’s name badge identifying one as a physician One should make patient as comfortable as possible One should sit in a chair directly facing the patient in order to make good eye contact Getting started The interviewer should sit in a relaxed position without crossing arms across the chest The crossed-arms position is not appropriate, as this body language projects an attitude of superiority and may interfere with the progress of the interview Getting started Making the patient feel that you are interested and concerned Once the introduction has been made, you may begin the interview by asking a general ,open-ended question “What medical problem has brought you to the hospital?” This type of opening remark allows the patient to speak first The interviewer can determine the patient’s chief complaint or the problem that is regarded as paramount（极为重要的） Getting started If the patient says “Haven’t you read my records?” It is correct to say “No, I’ve been asked to interview you without any prior information” or “I would like to hear your story in your words” Patients can determine very quickly if you are friendly and personally interested in them The narrative Novice （初学者）interviewers are often worried about remembering the patient’s history It is poor form to write extensive notes during the interview Attention should be focused more on what the person is saying and less on the written word The narrative After the introductory story, the interviewer should proceed to questions related to the chief complaint These should naturally evolve into questions related to the other formal parts of the medical history, such as the present illness,past illnesses, social and family history, and review of body system The narrative Patients should largely be allowed to conduct the narrative in their own way The interviewer must select certain aspects that require further details and guard the patient toward them The narrative Overdirection is to be avoided, because this stifles the interview and prevents important points from being clarified When patients use vague（含糊的） terms （术 语）such as “often”, “a little”, “sometimes”, the interviewer must always for clarification, ask “What does ‘sometimes’ mean?” or “How often is ‘often’?” The narrative The interviewer should be alert （警觉）for subtle clues from the patient to guide the interview further There are a variety of technique to encourage and sustain the narrative The closing By the conclusion of the interview, the interviewer should have a clear impression of the reason why the patient sought medical help, the history of the present illness, the patient’s past medical history If any part of the history needs clarification, this is the time to obtain it The closing At the conclusion, it is polite to encourage the patient to discuss any additional problems or to ask any questions “Is there anything else you would like to tell me that I have not already asked?” Thank the patient and tell him or her that you are ready to begin the physical examination Basic interviewing techniques Questioning（询问） Silence (沉默) Facilitation（简单化） Confrontation（面对面） Interpretation（解释） Reflection（反省) Support (支持) Questioning Open ended questions They are used to ask the patient for general information It is most useful in opening up the interview or for changing the topic to be discussed An open-ended question allows the patient to tell his story spontaneously and does not presuppose a specific answer Open-ended questioning What kind of medical problem are you having? Can you describe your feelings when you get the pain? Are you having stomach pain? Tell me about it Direct questioning After a period of open-ended questioning, the interviewer should direct the attention to specific facts learned during the open-ended question period This type of question gives the patient little room for explanation A direct question can usually be answered in one word or a brief sentence Direct questioning Where does it hurt? When do you get the burning How do you compare this pain with your ulcer pain? Notice: avoid asking direct questions in a manner that might bias the response Direct questioning Symptoms are classically characterized into several dimensions or elements, including bodily location, quality, quantity, chronology, setting, precipitating or palliating factors and associated manifestations These elements may be used as a framework to clarify the illness Direct questioning Bodily location Can you tell me where you feel the pain? Do you feel it anywhere else? Onset (chronology) When did you first notice it? How long did it last? Direct questioning Precipitating factors What makes it worse? What seems to bring on the pain? Palliating factors What do you do to get more comfortable? Does lying quietly in bed help you? Does eating make it better? Direct questioning Quality What does it feel like? Can you describe the pain? Radiation When you get the pain in your chest, do you feel it in any other part of your body? When you experience your abdominal pain, do you have pain in any other area of your body? Direct questioning Severity (quantity) How many times did you vomit? Can you fall asleep with the pain? Setting Does it ever occur at rest? Does the pain occur with your menstrual cycle? Direct questioning Associated manifestation Do you ever have nausea with the pain? Have you noticed other changes that happen when you start to sweat? O-P-Q-R-S-T It stands for onset (chronology), precipitating (palliative), quality, radiation, severity (setting), and temporal, is useful to help you remember these important dimensions of a symptom Question types to avoid Suggestive question It may provide the answer to the question “Do you feel the pain in your left arm when you get it in your chest?” A better way to ask the same question would be: “When you get the pain in your chest, do you notice it anywhere else?” Question types to avoid Why question It carries tones of accusation (谴责) This type of question almost always asks a patient to 阿 account for his/her behavior and tends to put the person on the defensive Why did you stop taking the medication? Why did you wait so long to call me? Try rephrasing the “Why” questions to “What is the reason…?” Question types to avoid Multiple question The patient can easily become confused and respond incorrectly, answering no part of the question adequately “How many brothers and sisters do you have, and has any one of them ever had asthma, heart disease, pneumonia, or tuberculosis?” Question types to avoid Medical jargon(行话) “You seem to have a homonymous（同侧） hemianopsia(偏盲）” Leading question or biased question It carries a suggestion of the kind of response the interviewer is looking for Always ask questions in the positive, not the negative “You don’t have diabetes, do you?” it should be “Do you have diabetes?”