Comprehensive Medical Communication History-Taking Guide

1. Medical Communication Jean ChowM.D.(KMC), M.A.(NKNU)

2. History "Credulous lady & astrologer" Known beginners of medical record: Forman & Richard Napier (from the Casebooks Project: ttp://www.magicandmedicine.hps.cam.ac.uk/

3. Forman(1552–1611) recorded over 10,000 consultations between 1596 and 1603, which were referred to as ‘casebooks’ . Richard Napier (1559–1634) Theodore de Mayerne filed some 1000 of his cases from 1603–53, headed with a name, date, complaint, then list a history, diagnosis, remedy/therapy and payment. Nicholas Culpeper (1616–1654) specialized in medical questions, but his records are lost. History An engraving of Simon Forman, from an original c. 1590. Image: Getty / Hulton

4. I. Medical Interview • History taking • Present Illness • Framework • SOCRATES (interview & write-up) • Identifying the chief complaint • Identifying/ Defining the problem • Past History • Family History Medical Communication

5. I. Medical Interview • Physical examination • Giving instructions • Explanation about… • The etiology • The patho-physiology Medical Communication

6. History-taking • Starting the interview • SOCRATES (interview & write-up) • Identifying the chief complaint • Identifying/ Defining the problem A. Present Illness

7. Starting the interview: What has brought you along today? • What seems to be the problem? • Problem= • Etiologic diagnosis, ex. arteriosclerotic heart disease • Physiologic finding, ex. congestive heart failure • Anatomic finding, ex. cardiomegaly • Symptom, ex. shortness of breath • Laboratory finding, ex. hypokalemia • Psychological problem, ex. depression • Risk factor, ex. excessive smoking A. Present Illness

8. Symptoms: What are your symptoms? I have n . I am suffering from n . A. Present Illness ~ENT problems~ a sore throat a bloody nose a stuffy nose a running nose a cough a headache an earache hearing loss tinnitus dizziness / vertigo ~Heart / lung problems~ chest pain tightness in the chest heartburn palpitations heart flutters rapid heart beat shortness of breath dyspnea

9. What are your symptoms? I am adj . I feel adj . A. Present Illness faint lethargic numb unwell weak constipated dizzy gassy itchy nauseous short of breath sluggish tired pregnant

10. What are your symptoms? I am V-ing . I v . A. Present Illness fainted gained weight lost weight gained appetite lost appetite vomited coughing up blood having chills having cold sweats sneezing vomiting blood

11. Symptoms: • WH question first • Ex. What are your symptoms? • Yes-No questions later • Ex. Do you have a fever? A. Present Illness

12. Chief complaint-centered – SOCRATES A. Present Illness

13. Site • Where does it hurt? • Can you point to the point that hurts? • What part(s) of the body does the symptom affect? • Onset • When did it start? • How long have you had this symptom? • Does the symptoms come and go?or is it constant? A. Present Illness

14. Character • Can you describe the pain? • What’s the pain like? • What kind of pain is it? • Radiation • Does the location of the symptom(s) change over time? • Does the symptom seem to travel around the body? A. Present Illness

15. Associated symptoms • Have you noticed any other symptoms? • Does any other discomfort comes with the symptoms? • Is there anything else you feel at the same time? A. Present Illness

16. Timing • How long does the symptom last? • How many times have you had this symptom? • What made you decide to visit the hospital? • Is there any recent change in your symptom? Tell me about it. • Has the symptom changed in some way? A. Present Illness

17. Exacerbating and relieving factors • What trigger(s) your symptom? • What make(s) your symptom better (or worse)? • Does …(lying down)… help the pain? • Severity • How bad is the symptom? • Does it affect your feelings, home life or work life? • To what degree are these parameters affected? A. Present Illness

18. Asking about suspected symptoms(using non-medical terms) • Do you have difficulty catching your breath? • Do you have any trouble holding your water? A. Present Illness

19. A. Present Illness • Greeting • What has brought you along today? • What seems to be the problem? • What are your symptoms? • How long have you had these symptoms? • How long has this been going on? • How long have you been v. ? • How many times did you have n. ? • Do you have a fever? • Do you have n. ?

20. B. Past history • Other systemic diseases • Principles • What other systemic diseases do you have? • When were you first told of the problem? • Where was your tender point? Could you point to it for me? • How was the problem treated? • What influence does it have (to daily activities)?

21. B. Past history • Other systemic diseases • History-taking tips • Do you suffer from any other illnesses? • How long have you had this illness? • When did this illness start? • How was this problem treated?

22. B. Past history • Previous illnesses • Principles • What? When? Where? How? Influence (to daily activities)? • Diseases vs. injuries • History-taking tips • Have you ever had any serious illnesses? • When was that? • How was this problem treated? • Have you ever been injured? • Have you ever received any operations?

23. B. Past history • Medication used • Principles • What? Why? How much? How often? Adverse effect? • History-taking tips • Are you taking any medication?

24. B. Past history • Allergies • Principles • What? Food? Air particles? • Medication? • History-taking tips • Do you have any allergies? • Are you allergic to any medication?

25. B. Past history • TOCC • Principles • For all fever and hospitalized patients • Travel history • Occupation history • Contact history • Cluster

26. B. Past history • TOCC • History-taking tips • Are you suffering from any infectious diseases? • Have you traveled to any countries with an epidemic recently? • What do you do for a living? • Have you been in unprotected close contact with anyone with the flu (hepatitis, AIDS, colds, influenza, chicken pox, measles)? • Are you staying with a cluster of persons with symptoms of recent epidemic or high morbidity risk?

27. B. Past history • Transfusion • History-taking tips • Have you ever had a blood transfusion? • When was that? • What was the transfusion for?

28. B. Past history • Habits • History-taking tips • Do you smoke? • How much do you smoke? Cigarettes or cigars? • Did you use to smoke? • Do you drink (drink alcohol)? • How often do you drink? What do you usually drink? • How much do you usually drink in 1 occasion? • Do you chew betel nuts? • How much do you chew every day?

29. B. Past history • Diet • History-taking tips • What is your usual diet? • Do you have any restrictions in your diet?

30. B. Past history • Diet • Diet restrictions • Low-salt diet due to hypertension • Low-fat diet due to atherosclerosis • Low-protein diet due to kidney disorders • Lactose-free non-dairy diet due to lactose-intolerance • Low-purine diet due to gout

31. C. Family history • Principles • Family composition up to three generations (grandparents and parents) • Family member, gender, age, alive/ deceased • Familial disease (AD, AR, XD, XR, polygenic) • Cause of death • Presented with Pedigree • List important or related ones

32. C. Family history • History-taking tips • Please tell me your family composition. • Does anyone in your family suffer from a disease? • Has anyone in your family passed away? • What did he / she die (pass away) of? • Does anyone of your siblings have the same problem?

33. Medical Communication • QUIZ • Listen to the dialogue and write down the keywords in English • Ms. Cane’s chief complaint: (1)____________________. • Reason for hospitalization: (2)____________________. • Past history: (3-5)__________ , ___________ , ____________. • Diseases with medication: (6-7) ____________ , ___________. • Allergies: (8) __________________ • Assistance needed for daily activities: (9) ______________ • Medical devices needed: (10) _____________________

34. References • 最新病歷記錄指引,台灣醫療品質協會,合記圖書出版社 • English in Medicine, Glendinning & Holmstrom, 3rd Ed, Cambridge University Press • Problem Oriented Medical Record (2009), 翁文能教授 http://www.ahqroc.org.tw/UserFiles/File/980815-4.pdf Happy histroy-taking !