MODULE 1 Taking a Health History

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Module Description and Content Goals:

Given topics on health history taking and collecting subjective data; texts that are varied and of a specialized and medical nature, which include information presented from dialogues and other sources (e.g. photographs, drawings, reference text /research information), the participant will use English with 70 % accuracy to:

1. Review and use idioms people regularly use to report when they are feeling sick. (Words and Expressions to Know).

2. Identify and demonstrate proper note-taking techniques; take notes of a health history. (Listening)

Identify and use some common medical abbreviations used in the recording of health histories. (Listening)

3. Listen for main ideas and details. (Listening)

4. Identify health history terms. (Speaking)

5. Review how to form questions properly. (Grammar) 6. Conduct an interview between a patient and a doctor taking a health history. (Speaking)

7. Identify the importance of giving patients enough time for responses, using open-ended questions and avoiding leading questions and. (Communication Tip)

8. Identify techniques of effective communication between health care workers and patients. (Reading).

Module 1 STUDENT HANDOUT H1:1

WORDS AND EXPRESSIONS TO KNOW:

A. The following expressions will be used in the dialogue you are about to hear. Read them carefully and then do the exercise that follows. After completing Exercise B, go back and write the meaning of the expressions in the chart.

Expression: Meaning: I haven’t been feeling myself lately. I’ve been out of sorts lately. I barely get through the day. I feel completely worn out (exhausted). I can’t fall asleep (go to sleep). I’ve been getting terrible headaches that interfere with my daily life. I have a splitting headache. I don’t think I can cope with it by myself. to be sick and tired of something I gave up smoking three years ago. over- the- counter drugs pain-killers A homeopathic remedy to burn the midnight oil to be a self-starter

B. Complete the sentences from the conversation you are about to hear using the words and expressions in Chart A. Each expression from chart A is used at least once.

1. A glass of wine every day used to be the only thing that helped me relax and ______at night. But even that doesn’t help me now. I have to take sleeping pills to ______.

2. I’ve been working in my restaurant for 20 years. I’ve been ______it. I‘ve been thinking about selling it.

3. I have been also taking a ______. It ‘s some kind of a natural medicine that is supposed to prevent headaches.

4. Do you still smoke? - I ______this nasty habit a year ago.

5. My son is a smart boy, but he is not much of a ______. He doesn’t burn ______studying.

6. I’ve been getting terrible headaches that ______my daily life. 7. I need a stronger ______. The ______pain-relieving medication doesn’t help me anymore.

8. I don’t know what has been happening with me lately, doctor, but I am not______. I feel tired all the time. I ______go through the day and I feel completely ______

______after doing anything.

9. I have a ______headache. I don’t think I can ______it by myself. I need some medication.

MODULE 1 STUDENT HANDOUT H1:2 LISTENING:

A. Tips for taking notes while interviewing a patient: When you are taking a health history, don’t expect to remember everything the client told you. Instead take notes so that the pertinent data are not lost and so there can be follow- up if some information needs clarification or expansion. The following are a few tips that can help you be a good note-taker:

 Don’t try to write everything; focus only on the important, new information.  Don’t write complete sentences, write key words only. Leave out words that are less important in conveying meaning (e.g. a, the)  Write clearly and leave plenty of space between points. Notes that are written too close together can be difficult to understand later.  Utilize time saving techniques such as writing figures instead of numbers in words (e.g. 3 instead of “three”). Take advantage of the abbreviations and symbols currently in use in the medical field (see the chart below).  If your hospital/practice is using a computerized medical record system, make sure you are making more contact with the patient than with the screen.

B. More than a thousand medical abbreviations are in use today. However, caution must be exercised when using abbreviations. Some of them may be misinterpreted because they have more than one meaning. If there is any question about which abbreviation to use, it is best to spell out the word or a phrase and not use an abbreviation. Consult a list of approved and unapproved abbreviations used in the health-care facility you are working at.

Here are a few abbreviations you may use in this module. More abbreviations will be introduced in other modules. Study these and then do the matching activity that follows. qd once a day PO orally, by mouth qod every other day prn as necessary bid twice a day R/O rule out tid three times a day SOB shortness of breath qid four times a day TAB tablet g gram DOB date of birth mg milligram y/o years old l liter c/o complains of ml milliliter D/C discontinue/stop hs hour of sleep, at bedtime, before bed, meds medication q every OTC over-the-the counter qh every hour @ at qAM every morning COPD chronic obstructive pulmonary disease qPM every evening MI myocardial infraction (heart attack) Helpful Hint: “ q” stands for the Latin word “quaque”, which means “every”. Knowing this will help you remember and understand a lot of abbreviations.

C. Match the abbreviations with their meanings 1. y/o _____ tablet 2. hs _____ once a day 3. DOB _____ milligram 4. Bid _____ years old 5. qd _____ discontinue 6. mg _____ at 7. PO _____ before bed 8. D/C _____ date of birth 9. q6h _____ twice a day 10. tab _____ every 6 hours 11. @ _____ by mouth

A. Listening for main ideas.

Dr. Howell is taking a health history of his patient Ms. Sandler. Listen to their conversation and take notes of the patient’s answers. Use the tips on note-taking you have just reviewed. Try to use some of the abbreviations you just learned, too. The first few notes have been taken for you:

 Name: Ms. Susan Sandelr______ Personal details: ______

______Chief complaint: extreme fatigue, no energy (tired, worn out, barely gets through day)

 Other symptoms: ______

 Medication: ______

 Substance use: ______

Compare your notes with your partner.

Now look at your notes and think which medical abbreviations from Chart B you could use to save you some time writing down the patient’s answers:

______Picture compliments of Microsoft clipart

B. Listen to the interview again. Pay attention to the questions the physician is asking his client. During each pause, fill in the blanks with these questions.

Dr. Howell: Come in, Mrs. Sandler. It’s been a while since I saw you. ______

Ms. Sandler: Hi, Dr. Howell. It’s good to see you. I don’t know what has been happening with me lately, doctor, but I am not feeling myself. I feel tired all the time. I barely get through the day and I feel completely worn out after doing anything. Then at night I can’t fall asleep. I’ve been getting terrible headaches that interfere with my daily life. I am unable to concentrate and make a lot of mistakes at work. I need your help. I don’t think I can cope with it by myself.

Dr. Howell: OK. I would be glad to help you, but first I need to see if there are any changes in your medical history. ______

______

Ms. Sandler: Yes, it’s still there, although I am thinking about selling it.

Dr. Howell: ______You are so good at what you are doing.

Ms. Sandler: I am sick and tired of it. I’ve been working there for 20 years. The business is not going very well now. Too much stress… I am ready to do something else.

Dr. Howell: ______

Ms. Sandler: We got divorced six months ago and he left…I am running the restaurant by myself now.

Dr. Howell: ______

Ms. Sandler: No, I… {Dr. Howell interrupts the patient} Dr. Howell: ______Ms. Sandler: Well, I gave up this nasty habit about 3 years ago. I just hope Ryan will quit too.

Dr. Howell: Ryan, your son, that’s right. ______

Ms. Sandler: He is 19 already, taking classes at Cy-Fair College.

Dr. Howell: ______

Ms. Sandler: He’s a smart boy, but he is not much of a self-starter. He doesn’t burn the midnight oil studying. As a result, he has poor grades.

Dr. Howell: Oh, dear! ______

Ms. Sandler: A glass of wine every day used to be the only thing that helped me relax and fall asleep at night. But even that doesn’t help me now. I have to take sleeping pills to go to sleep.

Dr. Howell: ______

Ms. Sandler: Tylenol PM, but it seems like I have to take more and more to get the same effect.

Dr. Howell: ______

Ms: Sandler: Two or sometimes even three.

Dr. Howell: ______

Ms. Sandler: No, just over-the-counter pain killers. But very often when I have a splitting headache, they don’t help even if they are maximum strength. I need a stronger medication, Dr. Howell. Maybe you could prescribe me something more effective.

Dr. Howell: ______

Ms. Sandler: Ibuprofen or Advil. I take 2 pills every six hours. I have been also taking a homeopathic remedy that is supposed to prevent headaches, but I don’t think it does any good.

Compare your notes with a partner. Listen to the conversation again. During each pause, repeat the phrase or sentence you just heard. Then read the dialogue with your partner using proper pronunciation and intonation.

C. A full case history covers:

o Personal details

o Chief complaint

o Past medical history

o Medication

o Substance use

o Family history o Social history

o Physical examination

Which steps in taking a medical history are not covered in this consultation?

______

SPEAKING and WRITING:

A. GRAMMAR NOTE: Forming Questions.

In this module, two types of questions have been used: Yes/No Questions and Wh-questions.

Yes/No Questions are questions that can be answered by “yes” or “no”. E.g. Do you still smoke? - Yes, I do. OR No, I don’t. Is he doing well at school? – Yes, he is. OR No, he isn’t.

WH-questions, also called information questions, require a longer answer as they are asking for specific information. They start with wh-words, such as who, what, where, when, which, why, how, etc.

E.g. How long ago did you quit smoking? – Three years ago. What kind of sleeping pills are you taking? – Tylenol PM.

The most difficult part in forming questions is to understand the word order in them. It is probably different from the word order of questions in your native language. The following formula will help you build Yes/No-questions and most of the WH-questions. Notice that in all of these questions a helping verb is used, and it is followed by a subject and a main verb. Think about Yes/No-questions and WH-questions in your mother tongue. Do you have to introduce a helping verb to form a question in your native language? WH-WORD + HELPING WORD + SUBJECT + MAIN VERB + REST of SENTENCE?

Does your husband feel the same way about the restaurant? Where do you live? Is he taking some homeopathic remedy? What kind of pills are you using?

Did you notice any other symptoms? When did this problem begin? Will you be able to continue doing your work? How will you monitor the sugar level in your blood?

There are two instances when a helping word is NOT used: 1. The main verb of the sentence is BE in Simple Present (am, is, are) and Simple Past (was, were). E.g.

WH-WORD + HELPING WORD + SUBJECT + MAIN VERB + REST of SENTENCE? Were you healthy before this happened? How old is your son? Notice that the main verb BE in simple present or simple past precedes the subject, that is, it has the same position as a helping verb.

2. When the question word is the subject of the question. The WH-questions most often used to ask about subjects are Who and What. E.g.

WH-WORD + HELPING WORD + SUBJECT + MAIN VERB + REST of SENTENCE?

Who buys and prepares the food you eat? What seems to be the trouble?

Notice that there is no helping word in either of these WH-questions.

B. Read the patients’ answers below. Write the nurse’s questions. Follow the example:

1. Question: Does anyone else in your family have the same problem? Answer: Yes, my Mother suffers from Diabetes.

2. Question: ______Answer: I am an accountant. 3. Question: ______Answer: It began two weeks ago.

4. Question: ______Answer: It is a severe, throbbing headache. My head is splitting from this pain.

5. Question: ______Answer: Yes, I think I’ll be able to change my eating habits. I’ll start to cook more and eat out less.

6. Question: ______Answer: My stomachache usually lasts anywhere from 30 minutes to an hour.

7. Question: ______Answer: I had my first child when I was 26.

8. Question: ______Answer: Jogging and gardening always make my back hurt more.

9. Question: ______Answer: Yes, I am. I am taking Centrum Multivitamin and Multimineral, the Advanced Formula.

10. Question: ______Answer: My first child was born in Vietnam.

Module 1 STUDENT HANDOUT 1:5 SPEAKING and WRITING: A. Study the case notes below. What do the abbreviations used here stand for?

______CASE 1 CASE 2

Name: Jeffry Bower Name: Donald Berger Occupation: roofer Occupation: accountant Age: 39 Age: 64 Meds: Albuterol 2.5 mg via Neb q 6 h Meds: Aspirin 81 mg TAB PO q d Chief complaint: cough Chief complaint: chest pain, SOB Other symptoms: SOB, chest tightness Other symptoms: dizziness, fainting, sweating wheezing

CASE 3 CASE 4

Name: Daisy Washington Name: Ms. Swan Occupation: retired teacher Occupation: bank teller Age: 72 Age: 31 Meds: OTC ascorbic acid 500 mg TAB PO q d Meds: Advil 200 mg TAB PO q 4-6 h Ferrous sulfate 325 mg TAB PO q d Chief complaint: R. sided temporal headache; Chief complaint: dizziness, vertigo, syncope severe, throbbing; lasts 24-48 hrs. Other symptoms: fatigue Other symptoms: blurred vision, nausea and vomiting

B. WRITING: Write the questions the doctor asked to obtain the information.

______

C. SPEAKING: Role play taking health histories of the above-mentioned cases. Be prepared to improvise and add your own details as these case summaries contain only the basic information.

D. While the aim of this speaking activity is to practice taking a health history and asking questions, try to analyze the data in each case and think about the possible diagnosis of each patient.

Case 1 ______

Case 2 ______

Case 3 ______

Case 4 ______

Module 1 STUDENT HANDOUT 1:6

A. COMMUNICATION TIP 1: When taking a health history, use open-ended questions. An open-ended question is designed to encourage a full, meaningful answer using the subject's own knowledge and/or feelings. It is the opposite of a closed- ended question, which encourages a short or single-word answer. Open-ended questions tend to be more objective and less leading. Using them will help you to avoid putting words in the patient’s mouth. Avoid phrases like:

I assume I presume I suppose I expect I imagine I am sure

Which of the questions below are open-ended? Rewrite the leading questions so they are more open-ended:

1. How is your appetite? ______

2. Do you eat a lot of fast food? ______3. I am sure your wife buys and prepares your food for you, doesn’t she? ______

4. I suppose you get short of breath after you exercise, right? ______

5. When did the problem begin? ______

6. I assume you feel tired when you get up, don’t you? ______

7. Are you getting terrible backaches as well? ______

8. What do you think caused this problem to start? ______

9. I imagine you’ve been feeling dizzy since you started to take this medication. ______

10. I presume you don’t know much about chronic obstructive pulmonary disease. ______

______

B. COMMUNICATION TIP 2: Allow time for responses. Give patients a chance to say what they have to say. There will be more time for your questions later.

Listen to the interview between Dr. Howell and Ms. Sandler again. Did Dr. Howell always allow his patient enough time to speak? What makes you think so? Prove your point.

______

Module 1 STUDENT HANDOUT H1:7 READING:

Pre- reading questions: 1. What could the doctors and other health care workers do to establish a better relationship with their patients? 2. What could the patients do better to improve their communication with their doctor’s office? Read this article and answer the questions that follow: STORY BY Karen Krakower

Scene opens on a man and woman seated opposite each other with folded arms and hostile expressions.

“He doesn't listen to a word I say.” “I would, but she doesn't talk.” “Why bother? You don't even look at me.”

Just another couple with their marriage counselor, huh. Wrong, and maybe worse: just another patient with their doctor. And like any relationship, it takes two to communicate—and two to misunderstand. Can this doctor's appointment be saved?

Ask Megan Cole, an actor—and visiting professor at The University of Texas Medical School at Houston—who is an expert in communication. She uses her well-honed talents to teach doctors how to "get into the minds of their patients, much like an actor who must reach into a character to understand the role." Some doctors have trouble communicating with their patients, just as some patients do with their doctors.

Reaching into the actor's tool kit, Cole teaches health care students and physicians how to talk, listen and relate to their patients. "But, it's a two- way street here. Patients must learn how to explain themselves, their symptoms, so that they can be helped," Cole adds.

Cole conducts her workshops and seminars for faculty and students as artist-in-residence through the UT John P. McGovern, M.D. Center for Health, Humanities and the Human Spirit.

The idea for a course in "empathy" began after Cole performed the groundbreaking stage play "Wit" in Houston. Cole originated the role in 1995 of the cancer patient whose emotional transformation occurs through exchanges between her and her doctors. Post-performance discussions between patients and doctors in the audience "moved me and I, too was transformed by the experience. I wondered what I could do to use my acting skills in a specifically useful way to help others."

Through discussions and interviews with patients and providers, Cole came up with a curriculum and a list of communication complaints and solutions that exist on both sides of the examining table:

“What do you think you have?” “I dunno, you're the doctor, you tell me.” Cole says that doctors note the following patient communication breakdowns:

 Being nonspecific about their symptoms  Patients not asking questions about their illness  Being unclear or reluctant to talk about their medical history  Coming in for an appointment only to say, "I'm fine."  No prioritizing of complaints  Not acknowledging a language or religious concern  Telling the admitting nurse one story, and the doctor, another  Not listening when the doctor is explaining  Paying more attention to piles of Internet information than to the doctor  Bringing interfering relatives onto the case  Not following doctor recommendations  Not sharing lifestyle/personal information  Being hostile  Being impatient

“You're fine. See you next year.” “But, I have a ques—”Door slams. Cole says that patients note the following medical-communication breakdowns:  Not paying attention  Constant interruption while patient is talking  Overuse of medical jargon  "Talking down" to the patient  Over-use of closed questions ("No history of heart disease, right?")  Talking to the chart or computer  Telling the patient how to feel  Not acknowledging that the patient has waited two hours in a paper gown for an appointment she booked months ago and for which she arrived on time  Ignoring patient's emotions or emotional reactions  Not answering questions or providing information sufficiently  Not offering language translation  Not acknowledging religious/spiritual concerns  Being hostile  Being impatient

If our car mechanics dismissed us and our rumbling engines with a brusque wave and grunt, we would never go back. And, as mechanics, if our customers roared in, demanded our attention, then stonewalled us when we asked what was wrong with the car, we’d find empathy hard to muster.

After all, Cole reminds us, “All physicians will be future patients; all patients will be future caregivers. Learn from each other, now.”

Cole teaches that the art of empathic listening is core to effective patient-caregiver communication. Health care professionals and patients are in relationships every bit as intimate and personal as familial ones-- even if they’ve never met before. And though both are working toward the same goal of restoring or maintaining health to the patient, both bring their own history, personality, daily stressors and worries to the encounter. The patients are terrified; the doctors are overworked. As one cancer survivor recalls, "You wait three hours naked, hairless, nauseated, and scared for yet another exhausted, HMO-jaded doctor to come in for three minutes, yawn, mispronounce your name, and leave."

Cole uses an "as if" approach to understanding each other. "In acting, even though we may not be exactly like a character, we can behave 'as if' we were that person. So if I want to be compassionate, as well as a skilled nurse, I will learn to act 'as if' I were those things."

Body language, vocal tone, physical touch, and spatial relationships (how close or far we place ourselves to someone else) speak louder than our words. Cole stresses that what we say or do may not be nearly as important as how we say or do it.

“So, John, let's sit down together and come up with an attack plan for these headaches...” Cole recommends these communication skills for health care providers:

 Knock on the door and wait for a response before entering.  Smile, shake hands and use the patient's name.  Sit eye-level or lower than the patient.  Sit 2 to 4 feet from the patient with no furniture obstacles between you.  Allow the patient to get personally organized.  Look through your glasses at the patient, not over or under.  Ask more open-ended questions. (“So, tell me about your job.")  Listen actively: nod, maintain eye-contact, limit note-taking.  Allow for thoughtful silences without feeling a need to fill in with conversation.  Show you’re hearing the patient by repeating phrases and reiterating.  Always acknowledge the patient's emotion before proceeding to the next issue.  See this person as a human being, not a disease process.  Remember, one day this may be you, your child, or your mother.

“I have a list of questions and I have written them down…” Cole's recommended communication skills for patients:

 Remember that a waiting room is just that. There are many patients and only one doctor. Sometimes you can't schedule your stomach flu.  Take the medical history questionnaire seriously. Leave nothing out, and what you don't know, make a point to find out for future visits.  Allow for silences between questions and answers.  Tell the doctor what you need from her. She is not a mind reader.  Describe your symptoms clearly. She does not have x-ray vision.  Listen actively: maintain eye-contact, let the doctor finish the explanation.  Bring another set of ears with you if necessary. Let them take notes.  Empower yourself with information from the Internet, but don't compete with your doctor.  Tell your doctor that you are frightened, angry or confused. Do not proceed to the next issue until these emotions have been addressed.  Share your lifestyle habits and secrets. Your doctor is not your mother or your judge.  Thank the staff for their help. It takes up to five staff members to see one patient.  See the care provider as a human being, not just as "the assigned physician referral."

Source: http://www.healthleader.uthouston.edu/archive/General_Health/2007/mars_venus-0606.html

Post-reading questions:

1. This article is about the communication between

a. marriage counselors and their clients

b. actors and health care workers

c. doctors and their patients

d. mechanics and their clients

2. Only doctors have trouble communicating with their patients. True False

3. Megan Cole teaches health care students and workers how to a. talk b. listen c. relate to their patients d. all of the above

4. Which one is not a doctors’ complaint about their patients:

a. Patients are inattentive.

b. Patients are following doctors’ recommendations.

c. Patients are inconsistent.

d. Patients trust the Internet information more than their doctors.

5. According to the article, all of these statements are correct:

a. Most patients understand medical terminology and slang. b. Doctors don’t take time to explain things thoroughly to their patients.

c. The patient feels that doctors are arrogant.

d. Doctors don’t see their patients in a timely manner.

6. According to the actor Megan Cole, verbal communication between doctors and patients is more important than non-verbal communication. True False

7. Different cultures can hinder a doctor from being an effective communicator. True False

8. Listen actively means:

a. taking detailed notes

b. maintaining eye-contact

c. using a tape recorder

d. maintaining silence all the time

9. Which one is not a communication shill Megan Cole recommends to health care providers:

a. Allow some time for patients to reflect on their answers.

b. Repeat after your patient and reiterate what he or she says.

c. Treat your patients the way you like to be treated.

d. Disregard your patients’ emotions.

10. Which of these is the communication skill Megan Cole recommends to patients:

a. Interrupt your doctor with questions.

b. Expect the doctor to guess your symptoms based on your appearance.

c. Tell your doctor about your daily routines and habits.

d. Hide your anxiety, fear and anger from the doctor. Picture compliments of Microsoft clipart