Good morning,
I am
Tamás FENYVESI
1
Good morning,
I am
Tamás FENYVESI
2
The medical interview
Anamnesis  αναμνησις
The main purpose: to gather all
basic information pertinent to the
patient’s illness, 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.
5
Communication is the key to a
successful interview.
Ask questions freely.
Permit the patient to tell his/her
story in his/her own words.
6
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!
7
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.
8
Remember the „rule of five vowels”
Audition: listen carefully
Evaluation: sorting out of relevant
Inquiry: additional question in the
relevant problems
Observation:notice…...nonverbal
communication (b.l.)
Understanding: the patient’s concerns
9
Beware!!!
The management may have a
different approach
10
11
The medical interview is the
basis of the good doctorpatient relationship
Flexible - spontaneous - not
interrogating
It is a powerful diagnostic tool.
12
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.
13
2.
Start with a very general “open-ended”
question e.g.:
“What problem has brought you to the
hospital?”
Do not start with reading of previous
medical reports!!
Persue the problems with more specific
open-ended questions:
“Tell me more about your chest pain.”
14
3. Direct questions to specific
facts learned during the openended questions:
where?
when?
how?
15
\
Symptoms (what the patient feels,
e.g. pain) are considered in the
classic „seven dimensions”:
1.Bodily location:
“Where in your back?” “Do you feel it
anywhere else?”
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
avoided
1.Yes or no 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.
21
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.
24
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.
25
“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.
30
31
The best questionnaire as a tool for
disclosing alcoholism is „CAGE”:
“Have you ever felt the need to cut
down on your drinking?”
“Have people annoyed you by
criticising your drinking?”
“Have you ever felt guilty about
your drinking?”
“Have you ever taken a morning
eye-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?
33
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”.
36
At this phase it is best to have
a checklist.
Customize clinical narrative to
electronic medical record
(EMC)
37
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? … palpitations? … nausea or
vomiting? … 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:
47
Symptoms of heart failure I.
1. Respiratory signsexertional 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….
49
NYHA Classification of HF
Class I —No limitation: Ordinary physical activity does not
cause undue fatigue, dyspnea, or palpitation.
Class II —Slight limitation of physical activity:
Such patients are comfortable at rest.Ordinary
physical activity results in fatigue, palpitation
dyspnea, or angina.
Class III —Marked limitation of physical activity:
Although patients are comfortable at rest,
less than ordinary activity will lead to symptoms.
Class IV —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.
50
Finally to end the interview
tactfully (e.g.):
“ shut up, please !”
51
The accuracy may be influenced in
different ways.
The history is not well enough
reproducible.
1. Different physicians ask the
questions in different way, and
interpret the answers differently.
52
2 Patients often give frankly different
answers to the very same question.
student
resident
consultant
(awkward situation)
Careful use of clear questions is
essential.
53
At this stage :
review the documentation of
past medical history
54
History is the key to doctor-patient
relationship and to
DIAGNOSIS!
55
The written history is a summary of the
information
obtained
during
the
interview:
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!!
57
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 entries for
“medical history taking”
Reached 20 08 2008
www.youtube.com/watch?v=u1x9M_S8fCw
a video example
61
62
“. . . For the secret of the care of the
patient is in caring for the patient.”
Francis Weld PEABODY, 1881-1927
63