The medical interview

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Good morning, I am Tamás FENYVESI
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Good morning, I am Tamás FENYVESI
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The medical interview

• Anamnesis ? a?aµ??s??
• The main purpose to gather all basic
  information pertinent to the patients illness,
  and the patients adaptation to illness.

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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)
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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
• Audition listen carefully
• Evaluation sorting out of relevant
• Inquiry additional question in the relevant
  problems
• Observationnotice...nonverbal communication
  (b.l.)
• Understanding the patients 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

• Greeting and introduction
• Mr. Smith, Im John Taylor a medical student.
  Ive 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 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.

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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 back? Do you feel it anywhere
  else?
• 2.Quality
• What does it feel like? Was it sharp, dull or
  aching?

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• 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?

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• 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?

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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?

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• (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?

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Do not write extensive notes during the
interview, it distracts you from observing the
pts 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

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• Confrontation
• Why are you so silent?
• You look upset.
• Interpretation
• You seem to be quite happy about that.

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• 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 pts 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
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• Each patient brings a different challenge
• silent
• overtalkative
• seductive
• angry
• insatiable
• ingratiating
• aggressive
• help rejecting
• demanding

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Format of the history

• Source and reliability
• Patient or else? hetero-anamnesis
• Chief complaint
• The patients brief statement why he/she sought
  medical attention.
• History of present illness
• What, when, how, where, which, who and why

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• Past medical history
• General state of healthPast illnessesHospitaliz
  ations
• InjuriesSurgeryAllergiesImmunisations

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• Substance abuseDietSleep patternsCurrent
  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 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?

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• Occupational and environmental history
• Exposure to disease-producing substances
• More than just listing the jobs duration pr
  otective devices?
• medical screening?

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

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• 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)

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Review of systems

• It S 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 Shortne
  ss of breath with exertion Shortness of breath
  when lying flat History of heart
  attack Rheumatic fever Heart murmur Last ECG

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• Other ? for heart function Fatigue Edema Cyanos
  is Hemoptysis (caughing up blood)

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• 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?

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• 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?

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• 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?

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Common causes of chest pain

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

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

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• Musculosceletal
• Costochondritis (Tietzes syndrome)
• Arthritis
• Muscular spasm
• Bone tumor
• Neural
• Herpes zoster

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

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

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• Patients often give frankly different answers to
  the very same question.
• student resident consultant
• (awkward situation)
• Careful use of clear questions is essential.

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At this stage review the documentation
of past medical history
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• History is the key to doctor-patient relationship
  and toDIAGNOSIS!

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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)

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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 200660279
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Robinson JD., Heritage J. Patient Education and
Counseling 200660279
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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
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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?vu1x9M_S8fCw a video
example
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. . . For the secret of the care of the patient
is in caring for the patient. Francis Weld
PEABODY, 1881-1927