1. Taking a Medical History: A surprisingly complicated procedure Sean Reed, M.D. Assistant Professor Department of Family Medicine

2. Content of Medical History Chief Complaint History of Present Illness Past Medical History Family History Social History (Patient Profile) Review of Systems

3. Feel like you are getting only half of a very complicated story You’re not at all sure where the story is going and you are afraid of wasting time You understand what the patient is saying, but you are not sure what is going on

4. Chief Complaint (CC) Patient’s main reason to seek care Agenda setting Hidden agendas

5. Chief Complaint: “My wife made the appointment for me” “I can’t find my penis” “Cell phone injury” … Family history of diabetes … Congestive heart failure … Five sutures to the forehead and a tetanus shot

6. “Is there something in particular that you are worried about?”

7. SKILLS DON E WELL OK, COUL D BE BETT ER NOT DON E OR DON E POOR LY NOT APPLICA BLE 1. Introduces self and explains purpose of interview. 321N/A 2. Attends to the patient’s comfort and privacy. 321N/A 3. Allows patient to describe the illness/chief complaint. 321N/A 4. Uses the following techniques effectively (Note: you don’t have to use them all!) Open-ended questions Reflection/Repetition Clarification Silence Facilitators (nods, uh-huh, etc…) Summation OVERALL USE OF INTERVIEWING TECHNIQUES 33333333333333 22222222222222 11111111111111 N/A 5. Balances listening with structure. 321N/A 6. Follows up on cues and vague statements. 321N/A 7. Attends to patient’s nonverbal cues. 321N/A 8. Responds empathetically and supportively. 321N/A 9. Closes interview appropriately. 321N/A

8. Power Tools/Techniques BENEFITS: Body posture and movements Eye contact Facial expression Inflection, tone of voice and rate of speech Touch Space between doctor and patient FOUCS: Facilitations Open-ended questions Clarification and direction Understanding by checking Surveying problems AVOID: leading questions multiple questions SUMMARIZE: Feedback to patient your understanding of story If you are lost If you are uncertain If done/transition

9. Getting started What brings you in today? How can I try and help today? What would you like to discuss today? I see that you have told the nurse…

10. History of Present Illness (HPI): Physician-centered framework: 7 Symptom characteristics –Location –Quality –Severity –Timing –Setting/context –Modifying factors –Associated symptoms

11. Pain History (“OPQRST”): Onset and Occasion when symptom first was noticed Provocative and Palliative factors Quality and/or Quantity of symptom Region of body and Radiation to other areas Severity of symptom (0 to 10 scale, if applicable) and associated Symptoms Time (duration) and Temporal associations (what is going on when symptom occurs)

13. Past Medical History Major illnesses Hospitalizations Surgeries Significant injuries Medications Allergies Immunizations Transfusions Gynecologic and obstetric history Psychiatric history

14. Past Medical History Medical Illnesses – identify chronic illnesses Hospitalizations - approximate dates Surgeries - approximate dates/reasons (ex: hysterectomy – benign or malignant?) Significant injuries

15. Past Medical History Medications –name, dosage, frequency, reason –OTC, herbal, vitamins, supplements Other alternative medicine therapies Allergies – describe reaction Immunizations Transfusions Gyn and Ob history –LMP, birth control use Past psychiatric history

16. Family History Current health of family Specific familial diseases Other family members with similar illnesses

17. “Patients rarely volunteer a family history of mental illness or addiction”

18. Social History / Patient Profile How do lifestyle or personality traits: Contribute to causality of illness? Aggravate or limit severity of illness Interfere or help with getting well The “usual day”

19. Social History/Patient Profile Demographic information Occupational and educational history –Military Travel history –Refugee history Health Habits –Smoking, Alcohol, Drug use –Exercise –Diet Sexual history Significant relationships Spiritual, cultural and health beliefs

20. What do you do for a living? What do you do for fun?

22. Review of Systems Uncover other medical problems Identify symptoms that may be related to presenting symptoms Move from general to specific questions –Positive responses need further clarification

23. SUMMARY Interviewing gems Is there something in particular that you are worried about? What do you do for a living? What do you do for fun? Don’t forget your power tools / techniques 7 Symptom characteristics –LocationSetting/context –QualityModifying factors –SeverityAssociated symptoms –Timing Summarize the visit Ask for questions Describe next step involve patient, if decision needed

24. Thank you for listening