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History of Present Illness (Chiba U.)

Session #2 of the Nihon University Clinical Skills in English Workshop
by

Daniel Salcedo

on 23 October 2013

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Transcript of History of Present Illness (Chiba U.)

A B C D E F G H I J K L M N
O

P

Q

R

S

T
U V W X Y Z

The History of Present Illness
Lisa Peters
27-year-old woman
I have a bad
headache

Maybe I should
see my doctor
Opening Questions
The interview should begin with open-ended questions that let patients express their concerns freely. At this point do not interrupt, just let the patient speak. Try to pick up any important information may provide.
Some commonly used questions are....
How can I help you today?
Why did you decide to come to the hospital today?
The nurse told me you have a headache, could to tell me more about it?
Lets see it in action!
I am Dr. Salcedo, one of the physicians here at the clinic, and I'll be taking care of you today, is that OK?
Good afternoon, are you Ms. Lisa Peters?
Yes I am, but please call me Lisa
Sure! Anything as long as you help me get rid of this headache...
Greeting
Opening Questions
So Lisa, can you tell me more about your headache?
Well I have been having these really annoying headaches for a while, actually since I started my new job at a fasion design company. I mean, I really love my job and my coworkers are so nice, but anyway, I get these headaches, and at first it was just once in a while but then they started coming more often and now I have them almost everyday.
What I'm worried about is that I remember that my grandmother used have some really terrible headaches and she passed away after having a stoke, so I just want to make sure everything is fine inside my brain.
Is there anything else you would like to tell me?
Encouraging Statements
We can use encouraging statements to help our patient's talk more during the open-ended question part of the interview.
Here Are some examples:
Is there anything else you would like to tell me?
Please continue
I see...
Aha....
(Head nodding)
Pro-Tip:

Time your encouraging statements carefully, using too many or too often may seem cold or uncaring
What else do we need to know?
In order to formulate a diagnostic impression we will need a lot more information from our patient.
But to get reliable information we must have a systematic approach.
What could be
causing Lisa's
headaches?
I need
more info

Onset
How the problem started and what factors were involved
What information are we looking for?
Gradual or sudden start
Factors that precipitated the problem
Onset
Lisa, how do your headaches usually start?
Well I'm not sure, but they usually start while I'm at the computer
Do the headaches usually start suddenly or gradually?
I guess they start little by little...
Typical Onset Questions
How did the pain start?
What were you doing when the pain started?
Were you
doing any physical

activity
when the pain started?
Did the pain start gradually or suddenly?
Pro-Tip:
If the patient experiences the symptom often, add "usually" to the question:
"How does the pain
usually
start?"
Provoking or Palliating Factors
Provoking factors make the problem worse

Palliating factors make the problem better
Provoking and Palliating Factors
Lisa, does anything make your headaches better?
Let me see... If I take some Tylenol they usually go away
Does anything make your headaches worse?
Sometimes they get worse when I'm under stress..
.
Do bright lights, like the computer screen make your headache worse?
Not really...
Typical questions abpout provoking and palliating factors
General Questions
What makes your headache better?
What makes your headache worse?
Specific Questions
Do
loud noises
make your headache worse?
Does
sleeping
make your headache better?
Pro-Tip
Ask each question separately, do not merge questions because the patient may get confused
Quality
Describing the basic characteristics of the pain or symptom
Quality
Lisa, is the headache sharp or dull?
It's a dull pain, kinda like a vise squeezing my head, constantly adding more pressure...
So the pain was pressure-like?
Yes, like a tight rubber band around my head.
Typical Questions about
Pain Quality
Is the pain
sharp
or
dull
?
Is the pain
constant
or
comes and goes
?
Is the pain like a
burn
?
Pro-Tip
It is important to try to find a common language between you and your patient. Asking open-ended questions at this point may lead to some very usual answers that can be hard to understand.
What is the pain like?
It feels like the universe exploded inside my head!
Region and Radiation
Region
: Location of the pain
Radiation
: Projection of the pain to another part of the body
Region and Radiation
Lisa, can you show me where the pain is?
...
So, the pain goes around your head from your neck, correct?
Yes, exactly like that...
Does the pain move anywhere else?
No, it just stays there
Typical Questions for Region and Radiation
Region
Can you show me where the pain is?
Radiation
Does the pain move anywhere else?
Pro-Tip
Ask the patient to
"show"
the pain, to avoid long complicated explanations. Never use the word
"radiate"
with patients, they tend to think of radiation.
Severity & other Symptoms
Severity
Focuses on attaching a numerical value to pain, this is non-comparable between patients but it gives an idea of how intense the pain is in that particular person

Other Symptoms
Ask about other symptoms related to your diagnostic impression, avoid unnecessary that do not offer additional value
Severity
Lisa, on scale from 1 to 10, 10 being the worst pain you have ever experienced, how would you rate the intensity of your headaches?
Like a 7 or 8...
How about when they first started?
About the same
Typical Severity Questions
On a scale from 1 to 10 (scale)
10 is the worst pain you have ever experienced (reference value)

How would you rate the intesity of your pain now? (question)
Initial Question
Follow-Up Questions
How severe was the pain when it started?
How severe is the pain now?
How severe was the pain 2 hours ago?
Other Symptoms
Lisa, do you feel nauseous when you have a headache?
Nope
Do you see any flashing lights or have visual problems before the headache starts?
Never
Do you have any other symptoms besides your headache?
Not really, it's just the headache
Typical questions about other symptoms
Symptom Specific Questions
Do you have
fever
?
Do you feel
dizzy
?
Have you been having
back pain
?
Have you been feeling
more tired than usual
?
Have you noticed any change in your
body weight
?
General Questions
Do you have any other symptoms?
Pro-Tip
When asking about symptoms, try to group your questions into categories to have a more organized and effective approach:
Red flags
General
Organ or disease specific
Timing
Questions about the specific timing of all the major symptoms. Like making a story of the symtoms and how they relate to each other.
If it is a chronic disorder try to establish the nature of the episodes.
Timing
Lisa, how many weeks ago did these headaches start?
Well it has been slightly over 3 months
And how times a week do you get the headaches?
About 3 or 4 times per week
And how many hours does each headache last?
Around 2 or 3 hours
Timing
Do the headaches always start at the same time?
Yes, usually in the late afternoon, around 4 or 5pm
Do the headaches happen on weekdays or weekends?
Hmmm, now that I think about it, only on the weekdays
Typical Timing Questions
About the Event
How many hours (minutes) does your pain last?
Is the pain getting better or worse?
About all the Episodes (Chronic or episodic pains)
How many times a week do you feel pain?
Are the pains becoming more frequent?
Do the pains usually appear in the morning or evening?
Are the pains worse on weekdays or weekends?
Does the pain change after meals?
Is the pain intensity always the same?
Pro-Tip
Always use units when asking questions about time, this prevents the patients from giving confusing answers
Closing the History of Present Illness
Lisa, is there anything else you would like to tell me about your headaches?
Not really, I think I told you everything I remember...
So, now I would like to ask you some questions about your health in the past, is that OK?
Sure doctor, ask away...
Typical Closing Questions
Is there anything else you would like to tell me about your pain?

I will now ask you some questions about your health in the past, is that OK?
Pro-Tip
Sometimes you may receive information that may totally change your diagnostic impression. Don't be afraid to ask further questions at this point.
My patient doesn't have pain!
What should I do???

Secretions
Typical Questions about Secretions
Typical Questions about Secretions
Let's Practice!
Advanced Clinical Skills Workshop
"Obtaining a History of Present Illness"
Today's Objectives
Opening the medical interview
Obtaining pertinent information of the patients current problem
Using "OPQRST" pain mnemonic
Obtaining a history from a painless patient
Daniel Salcedo MD
Chiba University School of Medicine
Chiba University
School of Medicine
Full transcript