Inquiry

1
Inquiry

• Department of Gastroenterology
• Ren-Ji Hospital
• Prof. Zhi Hua Ran

2
Inquiry

• It is the method that physician obtain the clinic
  data of patient, and further propose clinical
  judgment by comprehensive analysis
• Inquiry is the major methods of history taking
• It is a fundamental skill that every physician
  should know

3
Basic principles

• Good communication skills are the foundation of
  excellent medical care
• It improves health outcomes by resolving symptoms
  and reducing patients psychological distress and
  anxiety
• The quality of patient care depends greatly on
  the skills of interviewing, because the
  relationship that a patient has with a physician
  is probably the most extraordinary relationship
  between two human beings

4
Basic principles

• To gather all basic information pertinent (???)to
  the patients illness and the patients
  adaptation to illness
• An experienced interviewer considers all the
  aspects of the patients presentation and follows
  the leads that appear to deserve the most
  attention

5
Basic principles

• The clinician must be keenly aware of all clues,
  subtle or obvious
• Although body language is important, the spoken
  word remains the central diagnostic tool in
  medicine
• The art of talking and listening continues to be
  the central part of the doctor-patient
  interaction
• Once all the clues from the history have been
  gathered, the assimilation(??) of those clues
  into an ultimate diagnosis is relatively easy

6
Basic principles

• Communication is the key to a successful
  interviews
• It must be able to ask questions of the patient
  freely
• These questions must always be easily understood
  and keyed to the medical sophistication of the
  patient

7
Content of inquiry

• General data
• Chief complaint
• History of present illness
• Past history
• Review of systems
• Personal history
• Marital history
• Menstrual history
• Family history

8
General data

Name Sex Age
birth place
Native place Nation
Marital status Mail address
Profession Data of
admission Data of record
Source Reliability
9
Chief complaint

• It is the patients brief statement explaining
  why he or she sought medical attention
• It is the answer to the question
• What is the problem that brought you to the
  hospital?
• In the written history, it is frequently a quoted
  statement of the patient

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Chief complaint

• It should be one or two sentences including the
  time periods from onset to seeing the doctor
• Not the diagnostic term from the doctor

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Chief complaint

• Chest pain for the past 5 hours
• Terrible nausea and vomiting for 2 days
• Headache for the last week, on and off

12
History of present illness

• The history of the present illness refers to the
  recent changes in health that led the patient to
  seek medical attention at this time
• It describes the information relevant to the
  chief complaint
• It should answer the questions what, when, how,
  where, which, who, and why

13
History of present illness

• Chronology(????????) is the most practical
  frameworks(??) for organizing the history
• It enables the interviewer to comprehend(??)the
  sequential development of the underlying
  pathologic process

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History of present illness

• In this section the doctor gathers all the
  necessary information, starting with the first
  symptoms of the present illness and following its
  progression to present day
• It is important to verify that the patient was
  entirely well before the earliest symptom to
  establish the beginning of the current illness

15
History of present illness

• The character of symptoms
• location identity during
  intensity
• relief or provoke factors(????)
• Time during may be lasted for years, months, days
• It may also be of hours or minutes (in those with
  acute onset)

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History of present illness

• Causes and inducing factors
• investigate the causes that related with
  onset of the disease
• trauma intoxication
  infection
• inducing factors emotion diet
  environment
• Caution
• the causes that recently occurred may be
  easily recognized by the patient
• hardly recognized by the patients if the
  causes are complicated or if the courses lasted
  for years

17
History of present illness

• Progression
• including the changes in predominant
  symptoms or occurrence of new symptoms
• cirrhotic patient manifested some
  neurological signs, hepatic encephalopathy should
  be highly suspected
• chest pain lasted unusually and more
  severely than previous episodes(??) of angina,
  myocardial infarction should be suspected

18
History of present illness

• Accompanying symptoms
• it is useful in differential diagnosis
• e.g. patient manifested nausea, vomiting
  and fever,
• accompanied with jaundice and/or shock,
  acute biliary infection or acute pancreatitis
  should be considered

19
History of present illness

• Course of diagnosis and treatment
• The diagnosis and treatment the patient had
  received in other medical institution may provide
  informative data
• The diagnosis made by others could not
  replace ones diagnosis
• General condition during the course
• it may also provide some useful information

20
Past medical history

• The past medical history consists of the overall
  assessment of the patients health before the
  present illness include a statement of childhood
  and adult problems
• Parameters including
• general state of health
  past illness
• injuries
  hospitalizations
• surgery
  allergies
• immunizations
  substance abuse
• diet
  sleep patterns
• current medications
  alternative therapies

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Past medical history

• The patient should be asked about any prior
  injuries or accidents
• The type of injury and the data are
  important
• All hospitalization must be indicated, including
  admissions for medical, surgical, and psychiatric
  illness
• All surgical procedures should be specified. The
  type of procedure, data, hospital
• All allergies should be described. These include
  environmental, ingestible, and drug related
• It is important to determine the immunization
  history of all patients

22
Review of systems

• The review of systems summarizes in terms of body
  systems all the symptoms that may have been
  overlooked in the history of the present illness
  or in the medical history
• By reviewing in an orderly manner the list of
  possible symptoms, the interviewer can
  specifically check each system and uncover
  additional symptoms of unrelated illness not
  yet discussed

23
Review of systems

• The review of systems is best organized from the
  head down to the extremities
• Patients are told that they are going to be asked
  whether they have ever had a particular symptom
  and should answer Yes or no

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Review of systems

• Respiratory system
• cough identity frequency
• sputum production quantity
  appearance
• coughing up blood shortness of
  breath
• Cardiovascular system
• chest pain shortness of breath
  with exertion
• palpitations shortness of breath
  lying flat
• sudden shortness of breath while sleeping
• history of heart attack

25
Review of systems

• GI system
• appetite excessive hunger
  excessive thirst
• nausea constipation
  diarrhea
• heartburn vomiting
  abdominal pain
• change in stool color/caliber/consistency
• frequency of bowel movements vomiting
  blood
• rectal bleeding
  black tarry stools

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Review of systems

• Urinary system
• frequency urgency
  incontinence
• difficulty in the starting the stream
• excessive urination pain on
  urination
• burning blood in the urine
• bed-wetting flank pain history
  of retention
• urine color urine odor

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Review of systems

• Hematological system
• pallor yellow skin petechia
  purpura ecchymosis hematoma
• Endocrinological system and metabolite
• weakness profound
  sweating
• abnormal appetite weight change

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Review of systems

• Neurologic system
• fainting dizziness mood changes
• loss of memory speech disorders
• general behavioral change
  disorientation
• Musculoskeletal
• weakness paralysis muscle
  stiffness
• limitation of movement joint pain
• joint stiffness arthritis
  gout deformities

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Review of systems

• Review of systems may involved lots of clinical
  diseases
• One has to understand the pathophysilogical
  meaning of these signs and symptoms
• In each systems, it is practical to ask several
  symptoms
• The inquire may be intensified if there is
  positive symptoms/signs is elicited

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Personal history

• Social experiences
• birth place
• living area and duration particularly those
  epidemical areas
• education living condition hobby
• Profession and working place/condition
• Habit smoking (amount and duration)
• anesthetic drug(???)

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Unhealthy sexual history

• Unhealthy sexual history
• Sexually transmitted disease

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Marital history

• Marital history
• single or married
• age of marriage
• heath condition of partner

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Menstrual history

• Menstrual history
• age of menarche (first menstrual cycle)
• cycles and flow lasting
• amount of vaginal bleeding/discharges
• menopause and age of menopause
• Format
• flow lasting(day)
• menarche last
  menopause
• cycle(day)

34
Family history

• It provides information about the health of the
  entire family,living and dead
• Pay attention to possible genetic and
  environmental aspects of disease that might have
  implications for the patient

35
Skill and methods in inquire

• Getting started
• The narrative(??)
• The closing

36
Getting started

• The diagnostic process begins at the first moment
  of meeting
• One should be dressed appropriately, wearing a
  white coat with ones name badge identifying one
  as a physician
• One should make patient as comfortable as
  possible
• One should sit in a chair directly facing the
  patient in order to make good eye contact

37
Getting started

• The interviewer should sit in a relaxed position
  without crossing arms across the chest
• The crossed-arms position is not appropriate, as
  this body language projects an attitude of
  superiority and may interfere with the progress
  of the interview

38
Getting started

• Making the patient feel that you are interested
  and concerned
• Once the introduction has been made, you may
  begin the interview by asking a general
  ,open-ended question
• What medical problem has brought you to the
  hospital?
• This type of opening remark allows the patient to
  speak first
• The interviewer can determine the patients chief
  complaint or the problem that is regarded as
  paramount(?????)

39
Getting started

• If the patient says Havent you read my
  records?
• It is correct to say No, Ive been asked to
  interview you without any prior information
• or I would like to hear your story in your
  words
• Patients can determine very quickly if you are
  friendly and personally interested in them

40
The narrative

• Novice (???)interviewers are often worried about
  remembering the patients history
• It is poor form to write extensive notes during
  the interview
• Attention should be focused more on what the
  person is saying and less on the written word

41
The narrative

• After the introductory story, the interviewer
  should proceed to questions related to the chief
  complaint
• These should naturally evolve into questions
  related to the other formal parts of the medical
  history, such as the present illness,past
  illnesses, social and family history, and review
  of body system

42
The narrative

• Patients should largely be allowed to conduct the
  narrative in their own way
• The interviewer must select certain aspects that
  require further details and guard the patient
  toward them

43
The narrative

• Overdirection is to be avoided, because this
  stifles the interview and prevents important
  points from being clarified
• When patients use vague(???) terms (??)such as
  often, a little, sometimes, the interviewer
  must always for clarification, ask What does
  sometimes mean? or How often is often?

44
The narrative

• The interviewer should be alert (??)for subtle
  clues from the patient to guide the interview
  further
• There are a variety of technique to encourage and
  sustain the narrative

45
The closing

• By the conclusion of the interview, the
  interviewer should have a clear impression of the
  reason why the patient sought medical help, the
  history of the present illness, the patients
  past medical history
• If any part of the history needs clarification,
  this is the time to obtain it

46
The closing

• At the conclusion, it is polite to encourage the
  patient to discuss any additional problems or to
  ask any questions
• Is there anything else you would like to tell
  me that I have not already asked?
• Thank the patient and tell him or her that you
  are ready to begin the physical examination

47
Basic interviewing techniques

• Questioning(??)
• Silence (??)
• Facilitation(???)
• Confrontation(???)
• Interpretation(??)
• Reflection(??)
• Support (??)

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Questioning

• Open ended questions
• They are used to ask the patient for general
  information
• It is most useful in opening up the interview or
  for changing the topic to be discussed
• An open-ended question allows the patient to tell
  his story spontaneously and does not presuppose a
  specific answer

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Open-ended questioning

• What kind of medical problem are you having?
• Can you describe your feelings when you get the
  pain?
• Are you having stomach pain? Tell me about it

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Direct questioning

• After a period of open-ended questioning, the
  interviewer should direct the attention to
  specific facts learned during the open-ended
  question period
• This type of question gives the patient little
  room for explanation
• A direct question can usually be answered in one
  word or a brief sentence

51
Direct questioning

• Where does it hurt?
• When do you get the burning
• How do you compare this pain with your ulcer
  pain?
• Notice avoid asking direct questions in a
  manner that might bias the response

52
Direct questioning

• Symptoms are classically characterized into
  several dimensions or elements, including bodily
  location, quality, quantity, chronology, setting,
  precipitating or palliating factors and
  associated manifestations
• These elements may be used as a framework to
  clarify the illness

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Direct questioning

• Bodily location
• Can you tell me where you feel the pain?
• Do you feel it anywhere else?
• Onset (chronology)
• When did you first notice it?
• How long did it last?

54
Direct questioning

• Precipitating factors
• What makes it worse?
• What seems to bring on the pain?
• Palliating factors
• What do you do to get more comfortable?
• Does lying quietly in bed help you?
• Does eating make it better?

55
Direct questioning

• Quality
• What does it feel like?
• Can you describe the pain?
• Radiation
• When you get the pain in your chest, do you
  feel it in any other part of your body?
• When you experience your abdominal pain, do
  you have pain in any other area of your body?

56
Direct questioning

• Severity (quantity)
• How many times did you vomit?
• Can you fall asleep with the pain?
• Setting
• Does it ever occur at rest?
• Does the pain occur with your menstrual cycle?

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Direct questioning

• Associated manifestation
• Do you ever have nausea with the pain?
• Have you noticed other changes that happen
  when you start to sweat?

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O-P-Q-R-S-T

• It stands for onset (chronology),
  precipitating (palliative), quality, radiation,
  severity (setting), and temporal, is useful to
  help you remember these important dimensions of a
  symptom

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Question types to avoid

• Suggestive question
• It may provide the answer to the question
• Do you feel the pain in your left arm when you
  get it in your chest?
• A better way to ask the same question would
  be
• When you get the pain in your chest, do you
  notice it anywhere else?

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Question types to avoid

• Why question
• It carries tones of accusation (??)
• This type of question almost always asks a
  patient to ?account for his/her behavior and
  tends to put the person on the defensive
• Why did you stop taking the medication?
• Why did you wait so long to call me?
• Try rephrasing the Why questions to What is
  the reason?

61
Question types to avoid

• Multiple question
• The patient can easily become confused and
  respond incorrectly, answering no part of the
  question adequately
• How many brothers and sisters do you have,
  and has any one of them ever had asthma, heart
  disease, pneumonia, or tuberculosis?

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Question types to avoid

• Medical jargon(??)
• You seem to have a homonymous(??)
  hemianopsia(??)
• Leading question or biased question
• It carries a suggestion of the kind of
  response the interviewer is looking for
• Always ask questions in the positive, not the
  negative
• You dont have diabetes, do you?
• it should be Do you have diabetes?