Hawler Medical University College of Medicine DEPARTMENT OF INTERNAL MEDICINE. Practical CURRICULUM

Transcription

1 Hawler Medical University College of Medicine DEPARTMENT OF INTERNAL MEDICINE Practical CURRICULUM Dr. Abdullah Saeed Ibrahim Senior Lecturer Department of Internal Medicine 1

2 Hawler Medical University College of Medicine DEPARTMENT OF INTERNAL MEDICINE LENGTH: thirty Weeks First semester: fifteen weeks PURPOSE: History taking An extensive knowledge of medical facts is not useful unless a doctor is able to extract accurate and succinct information from a sick person about his or her illness. In all branches of medicine, the development of a rational plan of management depends on a correct diagnosis or sensible, differential diagnosis (list of possible diagnoses). Except for patients who are extremely ill, taking a careful medical history should precede both examination and treatment. A medical history is the first step in making a diagnosis; it will often help direct the physical examination and will usually determine what investigations are appropriate. More often than not, an accurate history suggests the correct diagnosis, whereas the physical examination and subsequent investigations merely serve to confirm this impression. The history is also, of course, the least expensive way of making a diagnosis. 2

3 Goals: 1. Demonstrates the ability to obtain and document an accurate and complete history from patient, caretaker or outside resources with moderate input from faculty. 2. Specific historical areas include: Risk factors for the disease considered Symptom driven history for patients presenting with: chest pain, shortness of breath, abdominal pain, weight loss, failure to thrive, infectious syndromes, acute renal failure, edema, delirium, syncope, rash Detailed past history for the diagnoses of CHF, DM, HTN, CAD, CRF, COPD/Asthma, HIV infection, thromboembolic disease, malignancy Risk assessment for in hospital complications of incontinence, falls, malnutrition, thromboembolic disease and delirium 3-Chart review for relevant information on transfer patients, including consultation with referring physicians 4-Begins to deal with sensitive topics such as:.compliance/adherence issues End of life issues in patients Sensitive histories such as sexual history, domestic violence history, psychiatric history, and substance abuse history 5-Learning to provide appropriate balance between supervision and autonomy of interns. Provides feedback to interns and student 6- Demonstrates the ability to obtain and document an accurate and complete history from patient, caretaker or outsideresources independently. 7-Successfully deals with sensitive topics. 3

4 schedule of time format :- 1 st week: introduction to history & how to communicate with patient and frame work of history taking. 2 nd week: discussion, demonstration of the patient s identification data & significance of it. 3 rd week: discussion, demonstration of the patient s chief complaint &duration. 4 th week: discussion, demonstration of how to take history of presenting complaint. 5 th week: discussion, demonstration Of how to take past history. 6 th week: discussion, demonstration how to take drug history. 7 th week: discussion, demonstration how to take family& social history. 8 th week: demonstration of how to take complete history by the lecturer(real &video assisted ). 9 th 14 th week : students taking history (witnessed ). 15 th week: examination of skills of history taking. 4

5 History-taking The history is a patient's account of their illness together with other relevant information that you have gleaned from them. It is good practice to make quick notes whilst talking to the patient that you can use to write a thorough history afterward don't document every word they say as this breaks your interaction! By the end of the history taking, you should have a good idea as to a diagnosis or have several differential diagnoses in mind. The examination is your chance to confirm or refute these by gaining more information. History-taking is not a passive process. You need to keep your wits about you and gently guide the patient into giving you relevant. Always remember, the data flows spontaneously from the patient, but the task of organization is yours. The standard history framework:- Identifying Data. Presenting complaint (s) &duration (PC). History of the presenting complaint (HPC). Past history (PH). Drug history (DH) Family history (FHx). Personal and Social History. Systematic enquiry (SE). 5

6 Identifying Data Name Age Sex Religion Occupation Address Marital status Date of admission. Date of history taking Source of the history usually the patient, but can be family member, friend, letter of referral, or the medical record. There are many situations when the patient may be unable to give a history (e.g. they are unconscious, delirious, demented, dysphasic etc.). In these situations, you should make an effort to speak to all those who can help you not only regarding what happened to bring the patient to your attention now, but also regarding their usual medication, functional state, living arrangements, and so on. When taking a history from a source other than the patient, be sure to document clearly that this is the case and why the patient is unable to speak for themselves. Date and Time of History. The date is always important. You are Strongly advised to routinely document the time you evaluate the patient, Especially in urgent, emergent, or hospital settings. Presenting complaint (s) &duration (PC) This is the patient's chief symptom(s) in their own words and should be no more than a single sentence. If the patient has several symptoms, present them as a list which you can expand on later in the 6

7 history, and order them chronologically. Ask the patient an open question such as what's the problem? Or what made you come to the doctor? Make every attempt to quote the patient s own words. For example, My stomach hurts and I feel awful. Sometimes patients have no overt complaints, in which case you should report their goals instead. For example," I have come for my regular checkup ; or I ve been admitted for a thorough evaluation of my heart. History of the presenting complaint (HPC) Here, you ask about and document the details of the presenting complaint. By the end of this, you should have a clear idea about the nature of the problem along with exactly how and when it started, how the problem has progressed over time, and what impact it has had on the patient in terms of their general physical health, psychology, social, and working lives. This is best tackled in 2 phases: First, ask an open question (as above) and allow the patient to talk through what has happened for about 2 minutes. Don't interrupt! Encourage the patient with non-verbal responses and make discreet notes. This also allows you to make an initial assessment of the patient in terms of education level, personality, and anxiety. Using this information, you can adjust your responses and interaction. It should also become clear to you exactly what symptom the patient is most concerned about. In the second phase, you should revisit the whole story asking more detailed questions. It may be useful to say I'd just like to go through the story again, clarifying some details. This is your chance to verify time-lines and the relationship of one symptom to another. You should also be careful to clarify pseudo-medical terms (exactly what does the patient mean by vertigo, flu or rheumatism?). Remember, this should feel like a conversation, not an interrogation! At the end of the history of presenting complaint, you should have established a problem list you should run through these with the patient, summarizing what you have been told and ask them if you have the information correct and if there are is anything further that they would like to share with you. It is also important to include pertinent positives and pertinent negatives from sections of the Review of Systems related to the Chief Complaint(s). These designate the presence or absence of symptoms relevant to the differential diagnosis, which 7

8 refers to the most likely diagnoses explaining the patient s condition. Other information is frequently relevant, such as risk factors for coronary artery disease in patients with chest pain, or current medications in patients with syncope. The present illness should reveal the patient s responses to his or her symptoms and what effect the illness has had on the patient s life. Always remember, the data flows spontaneously from the patient, but the task of organization is yours. Also we can ask specific questions about the diagnosis you have in mind (+its risk factors) and review of the relevant system. for each symptom, determine: The exact nature of the symptom. The onset: o The date it began. o How it began (e.g. suddenly, gradually over how long?) o If longstanding, why is the patient seeking help now? Periodicity and frequency: o Is the symptom constant or intermittent? o How long does it last each time? o What is the exact manner in which it comes and goes? Change over time: o Is it improving or deteriorating? Exacerbating factors: o What makes the symptom worse? Relieving factors: o What makes the symptom better? Associated symptoms. 8

9 For pain, determine: (SOCRATES) Site (where is the pain worst ask the patient to point to the site with one finger). Somatic pain often well localized, e.g. sprained ankle Visceral pain more diffuse, e.g. angina pectoris Onset Speed of onset and any associated circumstances Character Described by adjectives, e.g. sharp/dull, burning/tingling, boring/stabbing, crushing/tugging, preferably using the patient's own description rather than offering suggestions Radiation (does the pain move anywhere else?) Through local extension Referred by a shared neuronal pathway to a distant unaffected site, e.g. diaphragmatic pain at the shoulder tip via the phrenic nerve (C 3, C 4 ) Associated symptoms Visual aura accompanying migraine with aura Numbness in the leg with back pain suggesting nerve root irritation Timing (duration, course, pattern) Since onset 9

10 Episodic or continuous o o If episodic, duration and frequency of attacks If continuous, any changes in severity Exacerbating and relieving factors Circumstances in which pain is provoked or exacerbated, e.g. food Specific activities or postures, and any avoidance measures that have been taken to prevent onset Effects of specific activities or postures, including effects of medication and alternative medical approaches Severity Difficult to assess, as so subjective Sometimes helpful to compare with other common pains, e.g. toothache Variation by day or night, during the week or month, e.g. relating to the menstrual cycle Long-standing problems: If the symptom is long-standing, ask why the patient is seeking help now. Has anything changed? It is often useful to ask when the patient was last well. This helps focus their minds on the start of the problem which may seem distant and less important to them. Past history (PH) Lists childhood illnesses Lists adult illnesses with dates for at least four categories: Medical Surgical obstetric/gynecologic psychiatric 10

11 Includes health maintenance practices such as: immunizations, screening tests, blood transfusions, Traveling history and lifestyle Issues. Childhood illnesses, such as measles, rubella, mumps, whooping cough, chicken pox, rheumatic fever, and polio are included in the Past History. Also included are any chronic childhood illnesses. You should provide information relative to Adult Illnesses in each of four areas: Medical (such as diabetes, hypertension, hepatitis, asthma, HIV disease, information about hospitalizations, number and gender of partners, at-risk sexual practices). Surgical (include dates, indications, and types of operations); Obstetric/gynecologic (relate obstetric history, menstrual history, birth control, and sexual function); Psychiatric (include dates, diagnoses, hospitalizations, and treatments). You should also cover selected aspects of: Health Maintenance, including Immunizations, such as tetanus, pertussis, diphtheria, polio, measles, rubella, mumps, influenza, hepatitis B, Haemophilus influenza type b, and pneumococcalvaccines (these can usually be obtained from prior medical records) Screening Tests, such as tuberculin tests, Pap smears, mammograms, stools for occult blood, and cholesterol tests, together with the results and the dates they were last performed. Some aspects of the patient's past illnesses or diagnoses may have already been covered. Here, you should obtain detailed information about past illness and surgical procedures. Ask if they're under the doctor for anything else or have ever been to hospital before. Ensure you get dates and location for each event. There are some conditions which you should specifically ask patients about and these are shown below. 11

12 For each condition, ask: When was it diagnosed? How was it diagnosed? How has it been treated? For operations, ask about any previous anesthetic problems. Past medical history ask specifically about: Diabetes. Rheumatic fever.jaundice.hypercholesterolemia.hypertension.angina.myocardial infarction.stroke or TIA.Asthma.TB.Epilepsy.Anaesthetic problems.blood transfusions. For each condition that the patient reports having, ask exactly how it was diagnosed (where? by whom?) and how it has been treated since. For example, if the patient reports asthma, ask who made the diagnosis, when the diagnosis was made, if they have ever had lung function tests, if they have ever seen a chest physician at a hospital, if they are taking any inhalers? Occasionally, patients will give a long-standing symptom a medical name which can be very confusing. In this example, the patient's asthma could be how they refer to their wheeze which is, in fact, due to congestive cardiac failure. Allergies: This should be documented due to its importance. Ask if the patient has any allergies or is allergic to anything if they are unfamiliar with the term. Be sure to probe carefully as people will often tell you about their hay-fever and forget about the rash they had when they took penicillin. Ask specifically if they have had any reactions to drugs or medication. If an allergy is reported, you should obtain the exact nature of the event and decide if the patient is describing a true allergy, intolerance, or simply an unpleasant sideeffect. 12

13 Drug history (DHx) Clarifying questions in the drug history Tell me all the drugs or medicines that you take. Have any been prescribed from another clinic, doctor or dentist? Do you buy any yourself from a pharmacy? Are you sure you have told me about all tablets, capsules and liquid medicines? What about inhalers, skin creams or patches, suppositories, or tablets to suck? Were you taking any medicines a little while ago but stopped recently? Do you ever take any medicines prescribed for other people, such as your spouse? Do you use herbal or other complementary medicines? Here, you should list all the medication the patient is taking, including the dose and frequency of each prescription. You should make a special note of any drugs that have been started or stopped recently. You should also ask about compliance does the patient know what dose they take. Do they ever miss doses? If they are not taking the medication what's the reason? Do they have any compliance aids such as a pre-packaged weekly supply? The patient may not consider some medications to be drugs so specific questioning is required. Don't forget to ask about: Eye-drops. Inhalers. Sleeping pills. Oral contraception. Over the counter drugs (bought at a pharmacy), vitamin supplements. Herbal remedies. Illicit or recreational drug-use. Family history (FHx) 13

14 The make up of the current family, including the age and gender of parents, siblings, children, and extended family as relevant. The health of the family. You should ask about any diagnosed conditions in other living family members. You should also document the age of death and cause of death for all deceased first degree relatives and other family members if you feel it is appropriate. Review each of the following conditions And record if they are present or absent in the family: hypertension, coronaryartery disease, elevated cholesterol levels, stroke, diabetes, thyroid or renaldisease, cancer (specify type), arthritis, tuberculosis, asthma or lung disease,headache, seizure disorder, mental illness, suicide, alcohol or drug addiction,and allergies, as well as symptoms reported by the patient. It may help to draw a family-tree. Family trees Conventionally, males are represented by a square and females by a circle. The patient that you are talking to is called the propositus and is indicated by a small arrow ( ). Horizontal lines represent marriages or relationships resulting in a child. Vertical lines descend 14

15 from these, connecting to a horizontal line from which the children hang. You can add ages and causes of death. Family members who have died are represented by a diagonal line through their circle or square ( ) and those with the condition of interest are represented by shaded shapes ( ). Examples of single gene inherited disorders Autosomal dominant Adult polycystic kidney disease Huntington's disease Myotonic dystrophy Neurofibromatosis Autosomal recessive Cystic fibrosis Sickle cell anaemia Alpha thalassaemia Alpha-1-antitrypsin deficiency X-linked Duchenne muscular dystrophy Haemophilia A Fragile X syndrome Personal and Social History Smoking Attempt to quantify the habit inpack-years. 1 pack-year is 20 cigarettes per day for one year. (e.g. 40/day for 1 year = 2 pack-years; 10/day for 2 years = 1 pack-year). Equation: No. of cigarettes smoked per day * no. of years smoking 15

16 20 For example, a smoker of 10 cigarettes a day who has smoked for 15 years would have smoked: 10 *15=7.5 pack years 20 Ask about previous smoking as many will call themselves non-smokers if they gave up yesterday or even on their way to the hospital or clinic! Remember to ask about passive smoking. Be aware of cultural issues smoking is forbidden for Sikhs, for example, and they may take offence at the suggestion! If the patient remains reticent (I smoke a few), suggest a number but start very high (shall we say 60 a day?) and the patient will usually give you a number nearer the true amount (oh no, more like 20). If you were to start low, the same patient may only admit to half that. Alcohol You should attempt to quantify, as accurately as you can, the amount of alcohol consumed per week and also establish if the consumption is spread evenly over the week or concentrated into a smaller period. One unit is 10ml of pure alcohol. Asking bluntly 'How much alcohol do you drink?' may upset patients. Try 'Do you ever drink any alcohol?' Work out with them how much and when. Use open questions, giving permission for them to tell you, and do not judge them. Follow up with closed questions covering: What? When? How much? 16

17 Other useful questions are: When did you last have a drink? What's the most you ever drink? Hazardous drinking: This is 'at-risk' drinking and is the regular consumption of more than: o o 24 g of pure ethanol (3 units) per day for men (21units). 14 g of pure ethanol (2 units) per day for women.(14units). Binge drinking involving a large amount of alcohol causes acute intoxication and is more likely to result in trauma, e.g. a head injury, than if the same amount is consumed over 4 or 5 days. Everyone should have at least 2 days per week when they drink no alcohol. Harmful drinking: This is drinking that has caused physical or mental health damage or disruption to social circumstances Alcohol dependence: The use of alcohol takes a higher priority than other behaviors that previously had greater value An alcohol history Quantity and type of drink Daily/weekly pattern (especially binge drinking and morning drinking) Usual place of drinking Alone or accompanied Purpose Amount of money spent on alcohol Attitudes to alcohol Recommended weekly alcohol consumption: Recommends a maximum of 21 units/week for men and 14 units/week for women. Calculation the alcohol drink in unit: 1 unit= 10 ml of pure alcohol 17

18 X% proof = x units of alcohol per litre You have to know the strength of the drink Eg:40% drink i.e 40 of it is alcohol i.e 400ml of pure alcohol i.e 40 units/liter So the stander 750 ml (standard bottle) contains 30 units alcohol Examples 1 liter of 40% proof spirits contains 400 ml ethanol or 40 units ml (standard bottle) contains 30 units alcohol 3 1 liter of 4% beer contains 40 ml ethanol or 4 units ml can contains 2 units of alcohol Upbringing Birth injury or complications Early parental attachments and disruptions Schooling, academic achievements or difficulties Further or higher education and training Behavior problems Home life Emotional, physical or sexual abuse* Experiences of death and illness Interest and attitude of parents Occupation Current and previous (clarify exactly what a job entails) Exposure to hazards, e.g. chemicals, asbestos, foreign travel, accidents and compensation claims Unemployment: reason and duration Attitude to job Finance 18

19 Circumstances, including debts Benefits from social security Relationships and domestic circumstances Married or long-term partner Quality of relationship Problems Partner's health, occupation and attitude to patient's illness Who else is at home? Any problems, e.g. health, violence, bereavement? Any trouble with the police? House Type of home, size, owned or rented Details of home, including stairs, toilets, heating, cooking facilities, neighbors Community support Social services involvement, e.g. home help, meals on wheels Attitude to needing help Sexual history* Do you have a regular sexual partner at the moment? Is your partner male or female? Have you had any (other) sexual partners in the last 12 months? How many were male? How many female? Do you use barrier contraception - sometimes, always or never? Have you ever had a sexually transmitted infection? Leisure activities Hobbies and pastimes Pets Exercise What, where and when? Substance misuse* 19

20 *Only ask if it is relevant to the history. This is your chance to document the details of the patient's personal life which are relevant to the working diagnosis, the patient's general well-being and recovery/convalescence. It will help to understand the impact of the illness on the patient's functional status. This is a vital part of the history but sadly, perhaps because it comes at the end; it is often given only brief attention. The disease, and indeed the patient, do not exist in a vacuum but are part of a community which they interact with and contribute to. Without these details, it is impossible to take a holistic approach to the patient's wellbeing. Establish: Marital status. Sexual orientation. Occupation (or previous occupations if retired). o You should establish the exact nature of the job if it is unclear does it involve sitting at a desk, carrying heavy loads, traveling? Other people who live at the same address. The type of accommodation (e.g. house, flat and on what floor). Does the patient own their accommodation or rent it? Are there any stairs? How many? Does the patient have any aids or adaptations in their house? (E.g. rails near the bath, stairlift etc). Does the patient use any walking aids (e.g. stick, frame scooter)? Does the patient receive any help day-to-day? o Who from? (E.g. family, friends, social services.) o Who does the laundry, cleaning, cooking, and shopping? Does the patient have relatives living nearby? What hobbies does the patient have? Does the patient own any pets? Has the patient been abroad recently or spent any time abroad in the past? Does the patient drive? 20

21 Systematic enquiry (SE) After talking about the presenting complaint, you should perform a brief screen of the other bodily systems. This often proves to be more important than you expect, finding symptoms that the patient had forgotten about or identifying secondary, unrelated, problems that can be addressed. The questions asked will depend on the discussion that has gone before. If you have discussed chest pain in the history of presenting complaint, there is no need to ask about it again! Ask the patient if they have any of the following symptoms General symptoms Weight change (loss or gain), change in appetite (loss or gain), fever, lethargy, malaise, Sleep, mood. Respiratory symptoms Shortness of breath (exercise tolerance) Cough Wheeze Sputum production (color, amount) Blood in sputum (haemoptysis) Chest pain (due to inspiration or coughing) Cardiovascular symptoms Chest pain on exertion (angina) Breathlessness: o Lying flat (orthopnoea) o At night (paroxysmal nocturnal dyspnoea) o On minimal exertion - record how much o Palpitation 21

22 o o Pain in legs on walking (claudication) Ankle swelling Gastrointestinal symptoms Mouth (oral ulcers, dental problems) Difficulty swallowing (dysphagia - distinguish from pain on swallowing, odynophagia) Nausea and vomiting Vomiting blood (haematemesis) Indigestion Heartburn Abdominal pain Change in bowel habit Change in color of stools (pale, dark, tarry black, fresh blood) Genito-urinary symptoms Pain passing urine (dysuria) Frequency passing urine (at night, nocturia) Blood in the urine (haematuria) Libido Incontinence (stress and urge) Sexual partners - unprotected intercourse Men If appropriate: o o o o o Prostatic symptoms including difficulty starting - hesitancy Poor stream or flow Terminal dribbling Urethral discharge Erectile difficulties Women Last menstrual period (consider pregnancy) Timing and regularity of periods Length of periods Abnormal bleeding 22

23 Vaginal discharge Contraception If appropriate: Pain during intercourse (dyspareunia) Neurological symptoms Headaches Dizziness (vertigo or light-headed) Faints Fits Altered sensation Weakness Visual disturbance Hearing problems (deafness, tinnitus) Memory and concentration changes Musculoskeletal system Joint pain, stiffness or swelling Mobility Falls Endocrine system Heat or cold intolerance Change in sweating Excessive thirst (polydipsia) Other Bleeding or bruising Skin rash, Lumps, bumps, ulcers, and itch. 23

24 COMPLETING THE HISTORY TAKING When you think you have got all the relevant information from the patient you should have an idea of the likely diagnosis, or at least differential diagnoses. Your examination should elicit signs that will confirm or refute this. Before you examine the patient: Briefly summarize what the patient has told you. Reflect this back to the patient. This allows the patient to: o correct anything you have misunderstood o add anything that may have been forgotten. Tell the patient what you are going to do next. References:- 1. Macleod's clinical examination, 12th edition. 2. Oxford Handbook of Clinical Examination and Practical Skills, 1st Edition. 3. Hutchison's clinical methods 22th edition. 4. Bates guide to physical examination &history taking 8th edition. 5. Clinical methods in medicine SN chugh 1 st edition. 6. Clinical examination systematic guide to physical diagnosis 5 th edition. 7. Oxford Handbook of clinical medicine 7 th edition. 24