History Taking Basics Active Listening Cues • “Hmm.” • “I See.” • “Aha.” • “OK.” • “Go On.” • “What Else?” • “What Do You Mean by That?” • “I’M Sorry to Hear That.”
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TEAM MEDICS: History Taking History Taking Basics Active Listening Cues • “Hmm.” • “I see.” • “Aha.” • “OK.” • “Go on.” • “What else?” • “What do you mean by that?” • “I’m sorry to hear that.” “PEARLS” for Patient-Centered History Taking • Partnership: “Let’s deal with this together.” • Empathy: “That sounds hard.” • Apology: “I’m sorry this happened to you.” • Respect: “You obviously have worked hard on this.” • Legitimization: “Anyone would be upset by this situation.” • Support: “I’ll be here when you need me.” 1. Greeting & Introduction Student: Good morning/afternoon/evening. Patient: Hello S: Are you Mr. John Smith? P: Yes S: I’m Ami Suzuki, a medical student volunteer with the official volunteering organization, called Team Medics. I will be helping you before you see a doctor or nurse. P: Oh, I see, thank you. S: I’m going to ask you some routine medical questions, then translate your answers into Japanese, and make a hardcopy of your medical information so that Japanese healthcare professionals can have a better understanding of your condition. Of course I will keep any information you provide completely confidential. However, please note that I am a medical student, and I'm not allowed to diagnose your condition or prescribe medications. Based on your condition, I will refer you to an appropriate clinic or hospital accessible via public transportation. Would that be alright with you? P: Yes, that sounds fine. 1 TEAM MEDICS: History Taking 2. History Taking 2-1. Chief Complaint/Concern "How can I help you today?" “Please tell me more about the (symptom).” 2-2. History of Present Illness (OPQRST) Memorization tools: OPQRST is in alphabetical order so it would be too tricky to remember the keywords (Onset, Provocation, Quality, Region, Severity, Symptoms, Secretions, and Time) • Onset “When did you first notice the (symptom)?” “When did the (symptom) start?” “Did it start suddenly or gradually?” ! When/How/What was happening when the pain started • Provoking & Palliating factors “What makes the (symptom) worse?” “What makes the (symptom) better?” ! What worsens the pain (provokes) or lessens it (palliates) • Quality “Could you describe the (symptom)?” “Is the pain sharp or dull?” ! Description of what the patient is feeling (e.g. the pain can be described as dull, sharp, crushing, aching, tearing, throbbing, etc.) • Region & Radiation "Could you show me where the pain is?" "So the pain is located in (anatomical area), right?" "Does the pain move anywhere else?" ! Where the pain is located and whether or not it moves to another part of the body • Severity “On a scale of one to ten, ten being the worst pain you can imagine, how severe is the pain when it started/ ( ) hours ago?” “How about now?” "So, the pain is getting better (worse)?" ! How much pain the patient is suffering from, using a subjective 1 (least painful) to 10 (most painful) scale • Symptoms “Do you have (symptom: noun)?” (e.g. Fever, nausea ) “Do you feel (symptom: adjective)?” (e.g. dizzy) “Have you noticed any changes in your (habit)?”(e.g. appetite, bowel habit ) “Have you noticed any other symptoms?” ! relevant to differential diagnosis 2 TEAM MEDICS: History Taking • Secretions -stools, urine, phlegm, nasal/vaginal/wound/eye discharge Color: "What color is the (secretion)?" Appearance: “Could you describe the (secretion)?” Amount: “Do you have a large amount of (secretion)?” Frequency: “How often do you have the (secretion)?” Odor: “Have you noticed any unusual smell in the (secretion)?” Blood: “Have you noticed any blood in your (secretion)?” • Timing "When you have the (symptom), how long does it last? “Does the (symptom) come and go or do you have it all the time?” ! How the symptom affects the body, whether as a constant pain, waves, or in irregular patterns 2-3. PAM HITS FOSS • Previous presence of symptoms "Have you ever had the same problem before?" "When? /How many times? /Was it exactly the same as now?” • Allergies (medications, foods) “Are you allergic to any medications, foods or anything else?” “What happened when you got the allergy?” “How do you deal with it?” • Medications (prescription, OTC, and nutritional supplements) "Are you currently on any medications or supplements?" “Do you know what it’s called?” “Do you take it as the doctor prescribed?” HITS (Past Medical History) • Hospitalization "Have you ever been hospitalized?” = “Have you ever stayed at a hospital?" • Illness "Have you ever had any serious health problems in the past?” “Are you seeing a doctor for any other problems?” • Trauma "Have you ever had any major injuries in the past?” • Surgery “Have you ever had any surgeries in the past?” 3 TEAM MEDICS: History Taking 2-3. PAM HITS FOSS • Family history “Do any health problems run in your family?” “Does anyone in your family have (disease)?” • Obstetrics and Gynecology (OBGYN) (full transitions* required) “When was your last monthly period?” “Is there any possibility that you may be pregnant?” “Have you ever been pregnant in the past?” “Have you ever had an abortion or miscarriage?” • Sexual history (full transitions* required) "Are you currently sexually active?” "Do you have intercourse with men, women or both?" "How many sexual partners have you had in the last 12 months?" "Have you ever had any sexually transmitted diseases?" • Social history (SODA) (full transitions* required) • Smoking “Do you smoke?” “How many cigarettes do you smoke per day?” “How long have you been smoking?” “Hove you ever smoked in the past?” “When did you quit smoking?” “How long ago did you smoke?” “How many cigarettes did you smoke per day?” • Occupation “What’s your occupation?” “What’s your marital status?” • Drugs “Are you currently using any recreational drugs?” “Have you ever used any recreational drugs in the past?” “Which drugs do/did you use?” “How often do you use drugs?” “Have you ever had any drug related problems?” “What do you mean by “grass”?” (Cannabis) • Alcohol “Do you drink alcohol?” “How many drinks do you have in a week?” “Have you ever had any problems due to drinking?” CAGE questionnaire: If the patient reports more than 14 standard drinks per week (7-10 drinks per week for female patients) Cut down: “Have you ever felt you should CUT DOWN on your alcohol consumption?” Annoyed: “Have you ever felt ANNOYED when someone criticizes your drinking habit?” Guilty: “Have you ever felt GUILTY about your drinking habit?” Eye opener: “Have you ever had a drink first thing in the morning?” (EYE OPENER) 4 TEAM MEDICS: History Taking 2-4. Transitions • Simple Transitions “Mr Smith, I will now be asking you some questions about allergies.” • Full Transitions* Full transitions are necessary when asking about potentially sensitive information: • ObGyn • Sexual History • Social History • Introducing the new topic “I will now be asking you some questions about your sexual life.” • Reassuring the patient “These are some routine questions I ask all my patients.” • Provide confidentiality “Any information you provide will be completely confidential.” • Obtain permission “Would that be all right with you?” Sample Full Transitions: “I will now be asking you some questions about your sexual life. These are some routine questions I ask all my patients. Any information you provide will be completely confidential. Would that be all right with you?” 2-5. Case Summary “Now please let me summarize your story. Your headache started _____ (onset). The pain gets worse when _______ (provocation). The pain gets better when ________ (palliation). You feel (quality of pain) in (region). The pain travels (or moves) to (radiation). When you have the headache, the severity level is ___ out of 10, and now ___out of 10. (severity). You also have (or feel) ____, and/but no (or less) ______. (symptoms) Your pain occurs/occurred ____ (frequency) and lasts/lasted _______ (duration). Is that right?” 5 .