Post on 21-Jan-2016
Communication Communication with surgical with surgical
patientspatients(Surgical history taking)(Surgical history taking)
Prof. Prof. Galal AbouelnagahGalal Abouelnagah, FRCS, , FRCS, PHD, MDPHD, MD
Prof & head of Surgical Oncology unitProf & head of Surgical Oncology unit
Faculty of MedicineFaculty of Medicine
Alexandria UniversityAlexandria University
ObjectivesObjectives
Define effective history takingDescribe components of patient historyOutline patient interviewing techniquesIdentify strategies in obtaining historyTechniques facilitating History TakingSpecial challenges
What is it?What is it?
Patient interview in systematic way to:Patient interview in systematic way to:Recording necessary medical Recording necessary medical
informationinformation
+ Classical examination signs+ Classical examination signs
All information must be documented precisely and accurately
ImportanceImportance
Help for reaching diagnosisHelp for reaching diagnosisHelp in formulation treatment planHelp in formulation treatment planEvaluate medical progressEvaluate medical progressMedico-Legal recordMedico-Legal recordAvailability of information for:
ResearchReportable diseasesInsurance claims
ExampleExample
. . مدة من معايا بدأ والتعب دكتور يا جدا تعبان . أنا . مدة من معايا بدأ والتعب دكتور يا جدا تعبان أنا . تشوف عاوزك روشتة لى كتبوا كثيرة لدكاترة . رحت تشوف عاوزك روشتة لى كتبوا كثيرة لدكاترة رحت . . كله مستحمل عدتش ما و تعبت خالص أنا حل . لى . كله مستحمل عدتش ما و تعبت خالص أنا حل لى
. خالص. أعيش عارف مش .بيوجعنى خالص. أعيش عارف مش بيوجعنى
What the disease of that patient?What the disease of that patient?Which body system is affected?Which body system is affected?Since when disease started?Since when disease started?What treatment he received & does it What treatment he received & does it
help?help?
Types of patient interviewTypes of patient interview
Initial history takingInitial history taking Inward daily round: progress of Inward daily round: progress of
condition, results of investigations, condition, results of investigations, respond to treatmentrespond to treatment
Discharge interview: plain at homeDischarge interview: plain at home Follow up visit: New symptoms & signs Follow up visit: New symptoms & signs
since last visit, drug managementsince last visit, drug management Field research or screening questionnaireField research or screening questionnaire
Not just completing a formNot just completing a formTell patient your name and explain Tell patient your name and explain
why you are seeing himwhy you are seeing him
More important for medical studentsMore important for medical studentsCould be started before patient’s talkCould be started before patient’s talkGive patient whole your attentionGive patient whole your attentionDoctor should be an empathetic Doctor should be an empathetic
listenerlistener
General rulesGeneral rules
Consent Consent
Type of consents: Type of consents: • OralOral• BehavioralBehavioral• Written consent Written consent
Why:Why:• To get adequate information about case To get adequate information about case • Avoid medico-legal complainsAvoid medico-legal complains
Set the stageSet the stage
Provide safe environmentProvide safe environmentYour behavior and appearanceYour behavior and appearanceShake handsShake handsAvoid the patient’s personal spaceAvoid the patient’s personal spaceInquire about patient’s feelingsInquire about patient’s feelingsAvoid unfamiliar or street termsAvoid unfamiliar or street termsNote takingNote takingSigns of uneasinessSigns of uneasiness
(Body Language(Body Language ) )
Significance Action االرتياح أو الرضا أو
الموافقةاإلبتســــــــ
ــامــــه . العصبية أو الغضب
.أو الضيق
قضــــــــــم .الشفاه
المفاجأة أو عدم
التصديق أو الدهشة
رفع الحواجب مع
أو الكتف .
التهكم أو .السخرية
رفع مع الحواجب
ابتسامه مصطنعة
عدم الموافقة أو
الشعور لسلبى ا
تضييق العـــــــــــين
االهتمام أو العناية .
االنحناءلإلمام
القلق أو السأم أو التعب
الحركة الكثيرة فى الجلسة
االستقامة الثقة بالنفس . واالعتدال
.الجلسة فى
اإلنصات أو تركيز
االنتباه
تركيز العين فى عين
الطرف اآلخر التجنب أو
الالمبــــاالة أوالعصبية.
تجنب تالقى . األعــــين
. التثــاؤب الملل والضجر .
Guidelines for taking case Guidelines for taking case historyhistory
Questions should be open ended (encourage)Guidance of conversation but not restrictingAvoid leading questions (‘yes’ or ‘no’ answers)Clear & specific questionsAsk one question at a timeCover various aspects of diseased organDirect questions may be required sometimesPatient symptoms in his own words??
Special situationsSpecial situations
Infants under 5yrs; parent is Infants under 5yrs; parent is interviewedinterviewed
Unconscious patientsUnconscious patientsUnder drugs effectUnder drugs effectShying patientsShying patientsEmergency situationEmergency situation
In EmergencyIn Emergency
Fast the procedure but do not ignore Fast the procedure but do not ignore itit
In case of emergency, obtain In case of emergency, obtain information from patient and/or information from patient and/or bystandersbystanders
Classical history takingClassical history taking
Personal dataPersonal data Name:Name:• Full, accurateFull, accurate• Communicate with patientCommunicate with patient• Medico-legal aspectsMedico-legal aspects
Age:Age: • Date of birth is betterDate of birth is better• Growth and development is notedGrowth and development is noted• Certain diseases correlated with ageCertain diseases correlated with age• Management techniques according to ageManagement techniques according to age
Sex:• Some diseases shows sex predilection• Ethics & religious consideration
Marital status: Infertility, pregnant…
Contacts:• Address: endemic diseases, follow up visits• Phone• Nearest kin
Personal dataPersonal data
Occupation: Socio economic status
Race: Some certain diseases
Religious: Certain considerations
Date & type of admissionHospital number
Personal dataPersonal data
Chief ComplaintChief Complaint
First symptoms that caused First symptoms that caused patient to seek medical advicepatient to seek medical advice
Often:Often:PainPainBleedingBleedingAbnormal functionAbnormal functionObservation of a lumpObservation of a lump
Many complaints Always record patient’s own words In order of severity In chronological order
Present History Def.: Details of symptoms & their progress Should be well organized, clear, detailed
It is important to get right back to the beginning of the problem
Present History
Etiology (predisposing factors)
Classical course of disease
Any complications
Loco-regional effect
Systemic effect
Present historyPresent history
Negative information should be Negative information should be included if they contribute to the included if they contribute to the diagnosis or help exclude other diagnosis or help exclude other possibilitiespossibilities
Past & medical history
Past & medical history• AAllergy & anemiallergy & anemia• BBleeding disorders leeding disorders • CCardio respiratory disordersardio respiratory disorders• DDrug historyrug history• EEndocrine disordersndocrine disorders• FFits & faintsits & faints• GGastrointestinal disordersastrointestinal disorders• HHospital admissions & surgeriesospital admissions & surgeries• IInfectionsnfections• JJaundice & hepatic diseaseaundice & hepatic disease• KKidneyidney
Ask about health or cause of death of Ask about health or cause of death of patient’s parents, grandparents, brothers patient’s parents, grandparents, brothers and sistersand sisters
Previous similar illnesses in the familyPrevious similar illnesses in the family
Potential for hereditary diseasesPotential for hereditary diseases
Family historyFamily history
Reproductive historyReproductive history
Infertility of both sexes Infertility of both sexes Gynecological causes of abdominal Gynecological causes of abdominal
painpainPregnancy & lactationPregnancy & lactationAlso ask about:Also ask about:
Contraceptive useContraceptive useVenereal diseaseVenereal disease
Habits Habits
SmokerSmokerAthleticsAthleticsAppetiteAppetiteAlcoholAlcoholCoffeeCoffeeSexualSexual
Sensitive TopicsSensitive Topics
Alcohol or drug abuseAlcohol or drug abuse
Physical abuse or violencePhysical abuse or violence
Sexual issuesSexual issues
Psychiatric problemsPsychiatric problems
Sensitive Questions GuidelinesSensitive Questions Guidelines Respect patient privacyRespect patient privacy
Be direct and firmBe direct and firm
Avoid confrontationAvoid confrontation
Be nonjudgmentalBe nonjudgmental
Use appropriate languageUse appropriate language
Document carefullyDocument carefully Use patient’s words as possibleUse patient’s words as possible
Special ChallengesSpecial ChallengesSilence # overly talkative patientsSilence # overly talkative patientsPatients with multiple symptomsPatients with multiple symptomsAnxious patientsAnxious patientsAnger and hostilityAnger and hostilityCrying & depressionCrying & depressionConfusing behavior or historiesConfusing behavior or historiesLimited intelligenceLimited intelligenceDevelopmental disabilitiesDevelopmental disabilities
Barriers to CommunicationBarriers to Communication
May result from:May result from:Social or cultural differencesSocial or cultural differencesSight, speech, or hearing impairmentsSight, speech, or hearing impairments
Attempt to find assistance to aid in Attempt to find assistance to aid in communicationcommunication
Patient encouragesPatient encourages
Let patient continue talkingLet patient continue talkingFACILITATIONFACILITATION
““Tell me more about it”Tell me more about it”“ “ Please go on”Please go on”““I’m interested to hear about it “I’m interested to hear about it “
Rocking:Rocking: “Yes, Uh huh, umm, I “Yes, Uh huh, umm, I see”see”
Repeating:Repeating: ”It usually happens at ”It usually happens at night?”night?”
ConfirmationConfirmation
ClarifyingEx: “What do you mean by fretful?”
“Do you mean this . . . . ?”
خاطبوا الناس على " "قــــــدرعقولهم
Explain to the patients what is going onExplain to the patients what is going onEncourage patient to ask questionsEncourage patient to ask questionsNext plainNext plain
Thank the patientsThank the patientsDate & signatureDate & signature
FinallyFinally
Do notDo not
False quick diagnosisFalse quick diagnosisMalignancyMalignancyDebilitating diseaseDebilitating disease
False reassuranceFalse reassuranceMay be tempting May be tempting Avoid early assurance or “over Avoid early assurance or “over
reassurance” reassurance” Unless it can be provided with confidenceUnless it can be provided with confidence
Thank you….!Thank you….!
Any Questionswww.med.alexu.edu.eg/soncology