medical history and record taking

1 Consultation, medical history and record taking


The ability to take an accurate medical history from a patient is one of the core clinical skills and an essential component of clinical competence. The medical interview or consultation influences the precision of diagnosis and treatment, and studies have indicated that over 80% of diagnoses in general medical clinics are based on the medical history. It is estimated that a doctor might perform 200,000 consultations in a professional lifetime. All of which supports the need to learn and develop effective interviewing technique.


The success of the medical consultation depends not only on the doctor’s clinical knowledge and interview skills but also on the nature of the relationship that exists between doctor and patient. For this reason, increasing emphasis is being placed on communication skills alongside history-taking in medical training in order to enhance the doctor–patient relationship and promote more effective consultations. How we communicate is just as important as what we say. The patient needs to feel sufficiently at ease to disclose any problems and express any concerns, and to know they have been understood by the doctor. The patient also needs to reach a shared understanding with the doctor about the nature of any illness and what is proposed to deal with it. As well as being more supportive for patients, good communication skills make history-taking more accurate and effective.


In any consultation, the doctor has a number of tasks to perform. Ideally, these should be undertaken in a structured way so as to maximise the efficiency and effectiveness of the process. A number of consultation models exist but an increasingly influential model is the Calgary–Cambridge approach. This identifies five main stages in a consultation within a framework that provides structure and emphasises the importance of building a good doctor–patient relationship.




imageReview


The Calgary–Cambridge schema



• initiating the session

• gathering information

• physical examination

• explanation and planning

• closing the session

This chapter primarily addresses the first two stages: initiating the session and gathering information. It outlines the basics of taking a medical history within a framework that is patient-centred and emphasises effective communication. In addition, it describes an approach to recording information from the consultation in the clinical record.



The consultation


The medical consultation is the main opportunity for the doctor to explore the patient’s problems and concerns and to start to identify the reasons for their ill health. Traditionally, medical history-taking has been based on a conventional medical model and assumed that disease can be fully accounted for by deviations from normal biological function. It gave little consideration for the social, psychological and behavioural dimensions of illness. Consequently, if a patient presented with a history of headaches, for example, the doctor’s questions would be focused mainly on trying to identify the abnormalities of pathophysiology that were causing the symptoms, such as ‘Where does it hurt?’, ‘When did the headaches start?’, ‘What helps relieve the headaches?’.


Whilst abnormalities of pathophysiology are largely common to everyone with the same disease, not everyone with the same disease experiences it in the same way. The experiences of each person are unique because their social, psychological and behavioural perspectives are unique, and interact with abnormal pathophysiology to cause each patient to experience illness in a very individual way. Thus, more recent approaches to medical consultation stress not just assessment of biomedical abnormality but also assessment of psychosocial issues. Questions to identify psychosocial perspectives could include: ‘What most concerns you about your headaches?’, ‘What do your headaches stop you from doing?’, and ‘What do you think would help these headaches?’.


Unless a doctor can reflect on a patient’s psychosocial concerns, they risk failing to accurately diagnose the problem and may ultimately fail to effectively manage the patient’s illness. The amount of distress an individual experiences refers not only to the amount of pathophysiological damage but also to what the illness means to them and how it relates to their circumstances. Individuals who have suffered personal upset or are worried may feel ill even when no demonstrable disease is present. Good doctors have always known this, but there is now increasing emphasis in medical history-taking that it should be geared to exploring not just the symptoms of the body’s dysfunction but also the individual’s perspective of the symptoms. Models of history-taking are becoming increasingly patient-centred and seek to assess both the main components of ill health – the biomedical component and the psychosocial component.



STARTING THE CONSULTATION


There are three main aspects to initiating the session: preparation, establishing initial rapport, and identifying the patient’s problems and concerns.



Preparation


In preparing for a consultation, you should plan for an optimal setting in which to conduct the interview. In general practice or in the outpatient department, the consulting room should be quiet and free from interruptions. Patients often find that the clinical setting stokes up anxiety and thought should be given to making the environment welcoming and relaxing. For example, arrange the patient’s seat close to yours (Fig. 1.1), rather than confronting them across a desk (Fig. 1.2).


image

Fig. 1.1 The preferred seating arrangement when interviewing the patient: you are physically closer to the patient, without any barrier.


image

Fig. 1.2 A less than satisfactory seating arrangement. For the more sensitive or nervous patient, it will seem as though an additional barrier has been placed between him and the doctor, hindering the exchange of information.


Hospital wards can be busy and noisy, and it may be difficult to prevent your consultation being overheard and maintain confidentiality. If possible, therefore, try and find a quiet room in which to talk to the patient. If you consult with a patient at the bedside, sit in a chair alongside the bed, not on the bed, and ensure the patient is comfortable and able to engage with you without straining (Fig. 1.3).


image

Fig. 1.3 For the bedside interview sit in a chair alongside the bed. Ensure that the patient is comfortable and is able to look at you without straining.


Time management is important when preparing for the consultation. Ideally you should aim to avoid appearing rushed, and ensure that you set aside adequate time. Time constraints are often outside a clinician’s immediate control and one has to be pragmatic and comply with clinic appointment times. On the ward, rest periods and mealtimes are generally regarded as sacrosanct by the nursing staff, and it is usual courtesy to ask permission from them before encroaching on a patient’s time.


The patient’s first judgement of any healthcare professional is influenced by dress, which plays a role in establishing the early impression in the relationship. Whilst fashions change, most patients have clear expectations of what constitutes appropriate dress and it is advisable to adopt a dress code that projects a professional image. This may vary according to setting and patient group. For example, children may feel more at ease with a doctor who adopts a slightly more informal appearance. In addition to dress, you need to pay attention to personal hygiene; make sure, for example, that your hands and nails are clean.



Initial rapport


On first meeting a patient it is important to establish rapport and put the patient at ease. It’s a chance for you to demonstrate from the outset your respect, interest and concern for them. You should greet the patient, introduce yourself and clarify your role, giving the patient an outline of what your intentions are. It may sometimes be appropriate to give an idea of how long the interview might take.




‘Hello, my name is Jean Smith. I’m a medical student here at St Elsewhere and I wonder if I could speak to you about your condition? Your doctor, Dr Brown, has asked me to speak to you.’


Communication consists not only of verbal discourse but also includes body language, especially facial expression and eye contact. The first contact should also be used to obtain or confirm the patient’s name and to check how they prefer to be called. Some people like to be addressed by their first name, whilst others may prefer the use of their surname.



Identifying the problems and concerns


Begin by asking the patient to outline their problems and concerns by using an open-ended question (e.g. ‘Tell me, what has brought you to the doctor today?’). Open-ended questions are designed to introduce an area of enquiry but allow the patient opportunity to answer in their own way and shape the content of their response. Closed questions require a specific ‘yes’ or ‘no’ response.


Remember that patients often have more than one concern they wish to raise and discuss. The order of their problems may not relate to their importance from either the patient’s or doctor’s perspective. It is therefore particularly important in this opening phase not to interrupt the patient as this might inhibit the disclosure of important information. Research has shown that doctors often fail to allow patients to complete their opening statements uninterrupted and yet, when allowed to proceed without interruption, most people do so in less then 60 seconds.


Once the problems have been identified, it is worth reflecting on whether you have understood the patient correctly; this can be achieved by repeating a summary back to them. It is also good practice to check for additional concerns: ‘Is there anything else you would like to discuss?’ You may write down a summary of the patient’s comments, but constantly maintain eye contact and avoid becoming too immersed in writing (or using a computer keyboard). An example of what you may have written at this stage is shown in the ‘symptoms and signs’ box below.




imageSymptoms and signs


Written summary of patient problems



H.M., aged 57, housewife



• Increasing breathlessness for 3 months

• Night-time shortness of breath for 3 weeks

• A dry cough for the last 6 days

• Can no longer attend dance lessons


Gathering information: the history



EXPLORATION OF THE PATIENT’S PROBLEMS


You now need to explore each of the patient’s problems in greater detail from both biomedical and psychosocial perspectives. Gathering information on the patient’s problems is one of the most important tasks to be mastered in medicine. The doctor must use a range of skills to encourage the patient to tell their story as fully as possible whilst maintaining a degree of control and maintaining a structure in the collection of information. As the history emerges, the doctor must interpret the symptom complex. The manner in which the interview is conducted, the demeanour of the doctor and the type of questions asked may have a profound effect on the information revealed by the patient. Obtaining all the relevant information from the patient can be crucial in helping to formulate a correct diagnosis.


It is important that the patient feels that their welfare is central to the doctor’s concern, that their story will be listened to attentively, and that their information and views will be highly valued. Remember that most patients have no knowledge of anatomy, physiology or pathology and it is very important to use appropriate language and avoid medical jargon.




imageSymptoms and signs


Five fundamental questions you are trying to extract for the history



• From which organ(s) do the symptoms arise?

• What is the likely cause?

• Are there any predisposing or risk factors?

• Are there any complications?

• What are the patient’s ideas, concerns and expectations?

During the interview it is usual to use a combination of open-ended and closed questions. Normally, open questions are more commonly asked at the start of the interview with closed questions asked later, as information gathering becomes more focused in an attempt to elicit more detail.




imageQuestions to ask


Examples of open and closed questions



Open questions



• Tell me about your headaches.

• What concerns you most about your headaches?


Closed questions



• Is the headache present when you wake up?

• Does the headache affect your eyesight?

It is also useful to summarise a reflection of the information you have gathered at various times in the consultation: ‘So Mrs Smith, if I have understood you correctly, your headaches started two months ago and were initially once a week but now occur almost every day. You feel them worse over the back of the head.’ This is helpful not just because it allows you an opportunity to check whether you have understood the patient correctly, but can also provide a stimulus for them to give further information and clarification.



BIOMEDICAL PERSPECTIVE


Questions on the biomedical perspective should seek to clarify the sequence of events and help inform an analysis of the cause of the symptoms.


Symptoms from an organ system have a typical location and character: chest pain may arise from the heart, lungs, oesophagus or chest wall but the localisation and character differs. Establish the location of the symptom, its mode of onset, its progression or regression, its character, aggravating or relieving factors and associated symptoms.




imageSymptoms and signs


Symptoms helping distinguish different sources of chest pain



• Myocardial ischaemia – pressure, crushing, pressing retrosternal pain

• Pleuritic and chest wall pain – localised, sharp, distinct exacerbation with deep inspiration

• Gastro-oesophageal reflux pain – burning retrosternal discomfort (heart burn) arising from behind the sternum

For the assessment of pain, use the framework shown in the pain assessment box. The quality of the pain is important in determining the organ of origin. Patients often find it difficult to describe the quality of their symptom, so, if necessary, assist them by offering a list of possible adjectives (e.g. cramping, griping, dull, throbbing, stabbing or vice-like). Ask whether medication has been necessary to alleviate the pain, whether the pain interferes with work or other activities and whether the pain wakes the patient from sleep. It is difficult to assess pain severity. Offering a patient a numerical score for pain, from ‘0’ for no pain to ‘10’ for excruciating pain, may provide a quantitative assessment of the symptom.




imageSymptoms and signs


Pain assessment



• Type

• Site

• Spread

• Periodicity or constancy

• Relieving factors

• Exacerbating factors

• Associated symptoms


PSYCHOSOCIAL PERSPECTIVE


Information on psychosocial implications of a problem requires questions to be asked about a person’s ideas, concerns, expectations and the effect of the problem on their quality of life. For example, if you wanted to explore a patient’s psychosocial perspectives of their headaches, potential questions include those listed in the ‘questions to ask’ box.




imageQuestions to ask


To explore a patient’s psychosocial perspectives of their headaches



• What concerns you most about the headaches?

• What do you think is causing the headache?

• Is there some specific treatment you had in mind?

• How do the headaches affect your daily life?

Some people find it difficult to talk about their feelings and concerns and you need to be alert to verbal and nonverbal cues which might add insight to their thoughts and ideas. Following up on such cues can help facilitate further enquiry and might feel less threatening than more direct questions: ‘You mentioned that you were frightened that your headaches could be serious. Did you have specific cause you were worried about?’.


It is, of course, important to assess the impact of a problem on daily living by grading severity. For example, if the patient has intermittent claudication, ask how far the patient can walk before pain forces a rest. If breathlessness is a problem, ascertain whether the symptom occurs on the flat, climbing stairs, doing chores in the home or at rest. Gathering such information will allow a clearer understanding of the impact and meaning of an illness for each individual. Combining information on psychosocial perspectives with biomedical information adds to the diagnosis and provides a foundation to plan management.



BACKGROUND INFORMATION


The information gathered about patient’s problems needs to be set in context and individualised. The doctor must understand and recognise the patient’s background, how this impacts on the problem(s), and why the patient has sought help at this particular time. Such contextual information requires enquiry into a person’s family history, their personal and social history, past medical history as well as their drug and allergy history.



Family history


The family history may reveal evidence of an inherited disorder. Information about the immediate family may also have considerable bearing on the patient’s symptoms. Social partnerships, marriage, sexual orientation and close emotional attachments are complex systems which exert profound influences on health and illness. A useful starting point might be to ask if the patient has a regular partner or is married. If so, ask about their health status or any recent change in health status. If the patient has children, determine their ages and state of health. Enquire whether any near relatives died in childhood and if so, from what cause. When there is suspicion of a familial disorder, it is helpful to construct a family tree (Fig. 1.4). If the pattern of inheritance suggests a recessive trait, ask whether the parents were related – in particular whether they were first cousins.


image

Fig. 1.4 A standard family tree.




imageDifferential diagnosis


Common disorders expressed in families



• Hyperlipidaemia (ischaemic heart disease)

• Diabetes mellitus

• Hypertension

• Myopia

• Alcoholism

• Depression

• Osteoporosis

• Cancer (bowel, ovarian, breast)


Personal and social history


Just as with families, interactions with wider society can exert powerful influences on health and well being. We know, for example, that major health inequalities relate closely to social class and income, with socially and financially deprived individuals experiencing poorer health than people on higher incomes. A detailed social history includes enquiries about schooling, past and present employment, social support networks, and leisure. At this point, it is also convenient to ask about the use of tobacco and alcohol – the quantity smoked and the number of units drunk each week.



Education


Enquire about the age at which the patient left school and whether they attained any form of higher education or vocational skill. In addition to providing useful background information, this information provides a context for assessing diseases and disorders causing intellectual deterioration and social function.



Employment history


Enquire about working conditions as this may be very important if there is suspicion of exposure to an occupational hazard.


Patients may attribute symptoms to work conditions, e.g. a headache from working in front of a computer screen. Other problems such as depression, chronic fatigue syndrome and general malaise may also be blamed on working conditions. Although these associations may be prejudicial or coincidental, avoid dismissing them too readily. Frequent job changes or chronic unemployment may reflect both socioeconomic circumstances and the patient’s personality. It is useful to enquire about specific stress in the workplace, such as bullying or the fear of unemployment.




imageDifferential diagnosis


Occupational disease



• Asbestos workers, builders: asbestosis, mesothelioma

• Coal miners: coal worker’s pneumoconiosis

• Gold, copper and tin miners: silicosis

• Farmers, vets, abattoir workers: brucellosis

• Aniline dye workers: bladder cancer

• Healthcare professionals: hepatitis B

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Jul 18, 2017 | Posted by in GENERAL SURGERY | Comments Off on medical history and record taking

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