Chapter 2. Patient Assessment The purpose of obtaining a health history is to gather subjective data from the patient and/or the patient’s family so that the health care team and the patient can collaboratively create a plan that will promote health, address acute health problems, and minimize chronic health conditions. The health history is typically done on admission to hospital, but a health history may be taken whenever additional subjective information from the patient may be helpful to inform care (Wilson & Giddens, 2013). Data gathered may be subjective or objective in nature. Subjective data is information reported by the patient and may include signs and symptoms described by the patient but not noticeable to others. Subjective data also includes demographic information, patient and family information about past and current medical conditions, and patient information about surgical procedures and social history. Objective data is information that the health care professional gathers during a physical examination and consists of information that can be seen, felt, smelled, or heard by the health care professional. Taken together, the data collected provides a health history that gives the health care professional an opportunity to assess health promotion practices and offer patient education (Stephen et al., 2012). The hospital will have a form with assessment questions similar to the ones listed in Checklist 16.
Medically Reviewed by Minesh Khatri, MD on August 30, 2020 When you fill out forms at your doctor’s office, do you wonder why it matters whether or not your grandmother had high blood pressure or diabetes? Your doctor also asks you questions like this. Why is it important? Your medical history includes both your personal health history and your family health history. Your personal health history has details about any health problems you’ve ever had. A family health history has details about health problems your blood relatives have had during their lifetimes. This information gives your doctor all kinds of important clues about what’s going on with your health, because many diseases run in families. The history also tells your doctor what health issues you may be at risk for in the future. If your doctor learns, for example, that both of your parents have heart disease, they may focus on your heart health when you’re much younger than other patients who don’t have a family history of heart disease. If it’s possible, every adult should know their family health history. You may or may not already know some information about conditions that affected different family members. Even if you think you do, double-check what you know. Find out even more about as many blood relatives as you can, and remember to include half-sisters and brothers. You should not include people who are not blood relatives, such as: Make sure to write down what you learn, in case you forget details over time. You’ll also be able to add to the information you already have. Make sure to share the information with your siblings, children, or grandchildren, as they get older. To get started, call your relatives, or ask them in person about your family health history. Let your relatives know you’re not being nosy, but just want to gather details that could keep you and other family members healthy. You can offer to share what you learn, so that everyone can benefit from your research. You’ll want to ask about common chronic (ongoing) health conditions. Find out how old each person was when they learned about their condition. You may want to start by asking about these common family health problems: You’ll need to know the health history of relatives who have died, too. If you have access to death certificates or medical records, you can find out the cause of death and how old they were, but living relatives may know the details. If you were adopted, you may not know anything about your birth parents’ health history. If that’s the case, a big chunk of your medical history is a question mark. You may wonder if you’re at risk for heart disease, cancer, or other diseases that run in families. Rules vary by state, but most adopted people are able to access details about their birth parents’ family medical history once they become adults. Such information may be found through a state’s child welfare agency or the department that assists with adoptions. Once you find out your medical history, you can make powerful choices for yourself. If you learn, for example, that heart disease runs in your family, you may decide to make lifestyle changes that could lower your risk, such as quitting smoking, losing weight, or getting more exercise. Your doctor may also use the information to give you screening tests, which might catch a disease, such as cancer, early. There are lots of ways your medical history can put you and your doctor in better control of your health. AUTHOR: Barry J. Wu, MD, FACP Yale University CITATION: ABSTRACT: The medical interview remains the cornerstone of patient care for obtaining history, building relationships, and educating patients. A more patient-centered approach can improve not only patient satisfaction, but also physician satisfaction in enhancing the relationship with our patients. One approach in refocusing on a patient-centered medical interview is to obtain the history in reverse of a standardized form and begin with the social history followed by the family history, medications, allergies, past medical history, and history of present illness. The time to interview each patient should not be lengthened because of the order of the history taking. This reverse order history taking is an approach to consider; however, each interview is unique, and this approach is not appropriate for all situations. Key words: history taking, medical interview, medical history, social history, family history, patient care Despite the countless advances in technology and diagnostic imaging and testing, the medical interview is still essential for gathering information, building relationships, and educating patients.1 Moreover, a recent prospective study of patients admitted to the hospital demonstrated that 90% of correct diagnoses are made by the history, physical examination, and basic tests—without utilizing modern imaging studies.2 Unfortunately, the medical interview for newly hospitalized patients can suffer because of time constraints and can easily become more physician-centered and focused on completing checklists and sections in a standardized form, instead of eliciting a story of a particular patient’s illness. In 2001, the Institute of Medicine highlighted patient-centered care as one of six factors in high-quality health care.3 One approach in refocusing on a patient-centered medical interview is to obtain the history in reverse of a standardized form (Table 1) and begin with the social history followed by the family history, medications, allergies, past medical history, and history of present illness (Table 2). This reverse order in the history taking can be done in the same amount of time and can help foster the doctor-patient relationship; it can communicate your interest in the patient as an individual as well as enhance your understanding of the context of the patient’s illness. Furthermore, using more open-ended than closed-ended questions can help patients sense they have more time to elaborate on their story. A study by Beckman and Frankel4 showed physicians interrupt their patients from speaking on average after 18 seconds. This article will discuss a method of obtaining a history in a patient-centered approach and using open-ended questioning in reverse order of our traditional medical interview.
As you begin the interview with a new patient, it is important not only to introduce yourself, but also to demonstrate respect to your patient at the start by stating how much time you have together and what you will be doing. Moreover, you may foster the relationship building and enhance your patient’s sense of control by asking for your patient’s permission to be interviewed and examined. Physician-centered approach: “Hello, Mr Jones. My name is Dr Wu.” “Can you tell me what brings you to the hospital today?” Patient-centered approach: “Hello, Mr Jones. My name is Dr Wu.” “We will have 30 minutes together, and I will ask you several questions and then examine you to understand what the problem is. Is this OK with you?” SOCIAL HISTORY To get to know a new patient as a person, it may be helpful to begin the history taking by asking questions related to the social history. This may help the patient feel more at ease and can help you in understanding risk factors and background information that may be essential in formulating a differential diagnosis. Physician-centered social histories at times are limited to smoking, alcohol use, and drug use. However, it is a much richer section in the medical interview that includes a patient’s birthplace, education, occupation, functional status, diet, sleep, tobacco, alcohol, illicit drug use, sexual history, and religion, which may be important factors related to the current illness. This information may be key to developing an appropriate differential diagnosis for a particular individual. For example, you may think initially about tuberculosis more often than community-acquired pneumonia depending on where the patient was born or if there is a history of incarceration. It is also important at the onset of the interview to know the patient’s level of education so that you can communicate with the patient in language he or she understands. You would also want to appreciate the patient’s baseline status before the onset of illness. Thus, the initial questions may be about birthplace, education, and functional status. The social history is also an ideal section for patient education and to promote healthy behaviors and lifestyles and prevention of future disease. It is important to ask about smoking, alcohol, and illicit drug use with open-ended questions. If the patient denies smoking, this represents an opportunity to reinforce this behavior and remind him or her that smoking is related to the leading causes of death in adults, including myocardial infarction, cancer, stroke, and lung disease. Physician-centered approach: “Do you smoke?” “Do you drink?” “Do you use illicit drugs?” Patient-centered approach: “Let me start at the beginning. Tell me . . .” •“Where were you born?” •“What level of schooling have you completed?” •“What is a typical day like for you—what time do you wake up, what do you have for breakfast, then what do you do, what do you have for lunch, then what do you do, what you have for dinner, then what do you do, when do you go to bed?” “How much do you smoke?” “How much do you drink?” “What recreational drugs have you tried before?”
In obtaining the family history, avoid questions with a list of medical conditions that patients may have difficulty in answering. Instead, consider asking separately about the details of each first-degree relative and medical conditions that they have, followed by any other medical illnesses in other family members. Physician-centered approach: “Do you have any family history of heart attack, stroke, cancer, diabetes, hypertension, or hyperlipidemia?” Patient-centered approach: “Tell me about your mother.” “How old is she?” “What medical problems does she have?” Ask about the ages and medical conditions in your patient’s father, brothers, sisters, and children and then any medical illnesses that have occurred in other family members. MEDICATIONS/ALLERGIES It is essential to obtain an accurate list of all the medications that your patient is taking. Instead of using medical terms such as prescription and over-the-counter medications, it may be more helpful to use words such as pills, eye drops, nasal sprays, inhalers, ointments, injections, or suppositories and to ask whether medications were purchased at a grocery store, drugstore, or health store or on the Internet without a prescription. It is also important to know not only what your patient is allergic to, but also the reaction he or she experienced. Physician-centered approach: “Do you take any prescription medications?” “Do you take any over-the-counter medications?” “Do you have any allergies to any medications?” Patient-centered approach: “Tell me what pills you take regularly.” Ask separately about eye drops, nasal sprays, inhalers, ointments, injections, and suppositories. “Tell me about the pills you buy at the grocery store, drugstore, health store, or over the Internet.” “Tell me about foods, dyes, and medications that your body has had a bad reaction to.” PAST MEDICAL HISTORY A complete past medical history of your patient should include childhood, medical, surgical, obstetric, gynecologic, and psychiatric illnesses and immunizations. It helpful not just to list problems, but to include information such as the date of diagnosis, baseline laboratory data, complications, and treatments. Physician-centered approach: “Do you have diabetes?” Patient-centered approach: “What medical problems do you have?” Ask separately about surgical, obstetric, gynecologic, and psychiatric illnesses and the date of diagnoses, baseline laboratory data, complications, treatments, and immunizations. HISTORY OF PRESENT ILLNESS The history of the present illness tells the story. It includes the chief complaint, or some advocate the term chief concern to focus on the narrative of the patient’s story.5 It should include a description of the characteristics of the complaint or concern. One mnemonic is the OPQRST, which stands for onset; precipitating, palliating, and provoking factors; quality; radiation; severity; setting; timing; and temporal relation to the problem.6 It is also helpful to elicit the chronology of the problem and to determine whether the patient has experienced this problem before. In addition to the description of the complaint or concern, it is helpful to inquire about how the illness has impacted quality of life. An example of questioning about chest pain follows: Physician-centered approach: “Did the pain begin today?” “Did the pain get better or worse with walking?” “Is it a pressure pain?” “Does the pain go to down your left arm?” “Is the pain the worst you have ever felt?” “Did you have this pain before?” Patient-centered approach: “When did the pain start?” “What makes it better? “What makes it worse?” “How would you describe the pain?” “Where does the pain go?” “On a scale of 1 to 10, with 10 being the worst pain, how would you rate this pain?” “What were you doing when you experienced this pain?” “Have you had this pain before?” “How has this pain affected you?” REVIEW OF SYSTEMS This section helps uncover symptoms that may have been overlooked during the interview. It is helpful to prepare the patient by saying that you are going to ask a series of questions from head to toe to help ensure a complete history. While most of these questions will be phrased in a closed-ended fashion, some may be open-ended. An example follows for asking about weight loss: Physician-centered approach: “Any problems with weight loss?” Patient-centered approach: “Tell me about your weight.” LAST QUESTION Barrier, Li, and Jensen1 recommend that physicians use an expression at the beginning of the medical interview that allows patients to express their concerns, and they suggest the phrase “What else?” However, if you set it aside for the end of the interview, you may be able to discover important information related to the problem. For example, a patient may disclose that he is more concerned about the death of his dog the previous night after it was hit by a car than he is about his chest pain this morning. The use of an open-ended phrase instead of a close-ended phrase is more likely to elicit a reflection from the patient. Physician-centered approach: “Is there anything else I should know?” Patient-centered approach: “What else should I know?” CONCLUSION The medical interview remains the cornerstone of patient care for obtaining information, relationship building, and patient education. A more patient-centered approach can improve not only patient satisfaction, but also physician satisfaction in enhancing the relationship with our patients. The time to interview each patient should not be lengthened because of the order of the history taking. Each interview is unique, and this approach is not appropriate for all situations. This reverse order history taking is an approach to consider and reminds us of what Sir William Osler said: “The good physician treats the disease; the great physician treats the patient who has the disease.”7 Dr Wu is clinical professor of medicine at Yale School of Medicine. He is also associate program director of internal medicine and internal medicine clerkship director at Yale-New Haven Medical Center (Saint Raphael) Internal Medicine in New Haven, Conn. REFERENCES:
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What is the first question that is asked when obtaining an update on the patients medical history
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