Dr. Szathmári Miklós Semmelweis University First Department of Medicine 19. Sept. 2011.

1. Interviewing and health history. Structure and prupose of health history. Content of a comprehensive history. Evaluation of data Dr. Szathmári Miklós Semmelweis University First Department of Medicine 19. Sept. 2011.

2. The medical interview • The most important clinical tool available to health practitioners. • On the personal level: the interview is the task in medicine one will do the most often, and spend the most time on (120 000-160 000 interviews/40 years) • Professionally: It determines the problems addressed and helped. It forms the doctor-patient relationship. It is the medium of patient education about the illness, the diagnostic process, and the therapy • The interview has functions and structure

3. The three-function model of the medical interview Gathering data to understand a patient's problems Responding to patient's emotions Educating and encouraging patients to adhere totreatment recommendations

4. The significance of medical interview’s functions • Gathering data to understand a patient’s problem • The physicians interrupted their patients within the first 18 seconds of the encounter in 69% of interviews. In 77% of the interviews, patient’s reasons for coming to the physician were not fully elicidated. • Responding to patient’s emotions • While appr. 20% of medical patients suffer from significant psychiatric disorders (primary anxiety, depression, and substance abuse) studies indicate that at least half of these disorders are not recognized by physicians. • Patient education and motivation • When patients are asked to discuss their illness and its treatment – even inmediately after leaving their physician’s office – they are able to correctly identify only about 50% of critical information

5. Structure of the interview • The opening • The chief complaint • History of the present illness • Past medical history • Family history • Patient profile and social history • The review of systems • Evaluation of the mental status

6. The Medical Record Data for identification of patient • name • age • sex • race • marital status - occupation Source of referral • hospital • family physician - specialist Source of history • patient • family member • friend • health service, etc.

7. The opening of the medical interview • Introduction : nonverbal (good eye contact and extend a friendly hand in greeting) • verbal: Good morning Kovács Úr. My name is …, I am a student doctor. • Establish goals of the interview: • I am a student doctor learning how to interview patients • Obtain patient consent • Would you be willing to talk to me for a few minutes? • Establish initial connection and confidence • demonstrate interest in the patient: You seem to be in pain • Establish patient comfort • Before I ask you about your illness itself, I want to check how you are feeling right now?

8. The Chief Complaint • primary reason for the patient seeking medical attention • What problem brought you to the clinic? • should be recorded in the patient’s own words in quotation marks • initial facilitation: non verbal→ open ended questions → closed-ended (specific) questions • checking: correct any misunderstandings • probe to completeness: have I obtained all necessary information? • get information on the patient’s ideas about the meaning of the illness

9. Chief complaint and survey of problems • Pat.: Today afternoon I had a chest pain, and I could not catch my breath. I was so short of breath I thought I was dying. • Phys.: I am sure that must have been very frightening. Legitimation, expression of the empathy, and invites the patient to discuss the feelings in more detail • Pat.: I have never been so scared. I just could not get my breath. It was terrible. • Phys.: Please, tell me a bit more about the chestpain you have been having. (Facilitation) • Pat.: I was almost finished mowing the lawn when I suddenly got short of breath and noticed a heavy, tight feeling in my chest.

10. Chief complaint and survey of problems • Phys.: Attentive silence, or: Could you tell me more about the heavy, tight feeling? (facilitation methods) • Pat.: Well, I have never had anything like it before. It hurt, but it was more like an ache than a sharp pain. Then I noticed that the tight feeling spread to my back and down my left arm. • Phys.: Let me take a moment to make sure that I have understood you correctly. You said that you were just finishing mowing the lawn when you noticed the sudden onset of a sharp pain in your chest and had trouble breathing. (Cheking: a chance to correct any misunderstanding, and communicates a sense to the patient that the physician is listening and trying to understand)

11. Chief complaint and survey of problems • Phys.: What else is bothering you? (Survey of problems, the physician attempts to briefly scan the full range of a patients’s problems) • Pat: Well I have had some prostate trouble. • Phys.: What else? (probe to completeness) • Phys. Now that we have outlined all your problems, I’d like to hear from you about which ones bother you most? (partnership, expression of the empathy) • Pat: I’d really like to known more about this prostate thing. I think that’s causing my problem with sex. • Phys.: I’m concerned about your prostate also, but if it is alright with you, I think we need to make sure that we have dealt appropriately with the chest pain. There may be something we need to take care of right away. (Direction)

12. History of the Present Illness • most important part of the medical history • represents the effort by the physician to understand the full story of the development and expression of the chief complaint in the context of the patient’s life • The physician must work in partnership with the patient in order to develop an accurate and useful understanding of the illness in the patient’s life. • when necessary, interrupt the patient to prevent from getting „lost” in a sea of seemingly unrelated details • respond to patient’s emotions throughout

13. History of the Present Illness(Problem exploration) • Phys.: After you first noticed the pain, what happened next? • Pat.: I went inside to tell my wife. She said she was taking me to the hospital. • Phys.: Before we go on further, can you describe the pain in some more detail? The interviewer becomes more focused and uses progressively more specific and narrow questions to fill in specific details.

14. Seven core dimensions of any complaint • Location: • Phys: Can you take one finger and show me exactly where it hurts? • Quality: • Phys: Could you describe the pain? What is it like? • Severity: • Phys.: How bad was the pain? Pat.: It was terrible • Phys.: Was it the worst pain you have never experienced? • Timing: • Phys.: Can you tell me when this problem first started? • Context: • Phys.: Where you were and what you were you doing when you tend to get these chest pains? • Modifying factors: • Phys: Could you tell me what tends to help this pain?, Have you tried any medicines? • Associated signs: • Phys.:When you get this chest pain, what other sensations or feeling do you get?

15. Angina pectoris • Dull, tight, heavy or burning sensationmainly in the retrosternal arearadiating- upwards-to left- to right • rarely: may present in - epigastrium- back - jaw • Precipitated most frequently by- exertion- emotion- cold • Duration appr. 5-10 min; relieved by- nitroglycerin - cessation ofexertion

16. The typical clinical features of angina pectoris • The typical location of pain is retrosternal • When the patient is asked to localize the sensation, he or she will typically place their hand over the sternum, somtetimes with a clenched fist, to indicate the squezzing. The pain can not be localized with one finger. • Usually described as heaviness, pressure, squezzing, or choking • Usually associates with gradual intensification of symptoms over a period of minutes • It laststypically 2-5 min. • It can radiateto either shoulder and to both arms (especially the ulnar surfaces of the forearm and hand) • It can also arise in or radiate to the back, interscapular region, root of neck, jaw,teeth, and epigastrium. Rarely localized below the umbilicus or above the mandible. • Exertional angina is typically relieved by rest and nitroglycerin

17. Past medical history • previous illnesses; time of onset, duration, outcome, effect onpatient's life • Please, tell me about your previous hospitalizations • Can you tell about any serious or troubling illnesess you have had in the past? • surgery, traumas • Have you had any surgeries? • hypersensitivity to drugs, X-ray contrast media • Do you have any allergies?

18. Family history It focuses on the health problems of the patient’s closest relatives. These data can be important in ivestigating the possibility of genetically transmitted diseases. -Please tell me about your parent’s health. • record present age and health • if dead, state cause and age at death • note occurrence of similar or associateddiseases within the family • Are there any other illnesess that run in your family? • Has anyone else in the family ever had problems like yours? • Finally, screening question: • Has anyone else in the family ever had trouble with high blood pressure, neoplastic disorders, tuberculosis, mental diseases?

19. Patient profile and social history This should encompass the following: • the patient's household circumstances and occupational environment;inter-personal relationships at home and at work;occupational history– employed / unemployed; stability of jobtenure; occupational hazards. • Can you tell me a little about how you spend your time? • Some impression of the patient's lifestyle; Negative health habits represents important risk factors and need to be evaluated. Since alcoholism is very common, and since denial is so common among alcoholics, special interviewing techniques are usually required to elicit a history of alcoholism.

20. Questions to explore the possibility of alcohol abuse • Have you ever felt the need to cut down on your drinking? • Do you ever get annoyed when people tell you to cut down on your drinking? • Do you ever feel guilty about drinking too much? • Do you ever need an „eye-opener” in the morning? If the answers yes to any of these questions, the possibility of alcohol abuse is present, and physicians should try to get an approximate amount of alcohol consumed.

21. Review of systems Cardiovascular and respiratory systems: • Did you have chest pain on exertion or at rest? • Did you feel palpitation or irregular rhythm? • Did you experience ankle edema? • What about things like shortness of breath, coughing? • Did you have hemoptysis? Digestive system: • Do you have trouble with your stomach? • What about things like stomach pain, trouble with your bowels, or nausea? • What about bowel habit–recent change; stoo1s–blood / pallor / odour / mucus / incontinence Genitourinary system: • Any trouble with your urine? • What about things like painful or frequent urination, unusuel color or smell? • Do you have any problem with the erection, ejaculation/Time of last period, cycle length; duration and amount of menstrual flow • State the total number of pregnancies and abortions. Note complications of pregnancy or labour. Enquire about the current health ofany children. Note the method(s) of contraception used, if any.

22. Piting edema Low albumin, immobility, and venous insufficiency have lead to accumulation of fluid in lower extremity. Note residual imprint of fingers following application of pressure.

23. Review of systems • Hematologic system: • Any trouble with easy bruising or bleeding? • Endocrine system: • Do you get colder or hotter than others around you? • Immunologic system: • Any trouble with infections?

24. Review of systems • Musculoskeletal system: • How are your joints and muscles? • What about things like pain, swelling, or weakness? • Neurological system: • Any trouble with your sense of smell or taste? • Any problems with weakness in your arms or legs or unusual feelings like „tingling”? • Any trouble with the balance or walking? • Any trouble with the memory? • Psychiatric system: • How have your nerves been? • Any problems with anxiety or depression?

25. Summary • Two thirds of diagnoses can still be made by the history alone, despite the technological innovations of modern medicine. • One of the essential qualities of the physician is interest in humanity, for the secret of the care of the patient is caring for the patient. • Physicians are becoming increasingly involved with attempts to influence patients’ behaviors.The inability to achieve patient compliance can entirely undermine the impact of a physician’s diagnostic or socioemotional skills.