InquiryInquiry

Department of Gastroenterology

Ren-Ji Hospital

Prof. Zhi Hua Ran

Inquiry 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

Basic principles 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

Basic principlesBasic principles

To gather all basic information pertinent ( 相关的） to the patient’s illness and the patient’s adaptation to illness

An experienced interviewer considers all the aspects of the patient’s presentation and follows the leads that appear to deserve the most attention

Basic principlesBasic 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 （消化） of those clues into an ultimate diagnosis is relatively easy

Basic principlesBasic 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

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

General dataGeneral data

Name Sex

Age birth place

Native place Nation

Marital status Mail address

Profession Data of admission

Data of record Source

Reliability

Chief complaint Chief complaint It is the patient’s 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

Chief complaint 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

Chief complaint Chief complaint

“Chest pain for the past 5 hours”

“Terrible nausea and vomiting for 2 days”

“Headache for the last week, on and off”

History of present illnessHistory 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

History of present illnessHistory of present illness

Chronology （按年月次序的排列） is the most practical frameworks （框架） for organizing the history

It enables the interviewer to comprehend （理解） the sequential development of the underlying pathologic process

History of present illnessHistory 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

History of present illnessHistory of present illness

The character of symptoms

location identity during intensity

relief or provoke factors （触发因素） Time during may be lasted for years, months, day

s It may also be of hours or minutes (in those with

acute onset)

History of present illnessHistory 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

History of present illnessHistory of present illness

Progression including the changes in predominant symptoms

or occurrence of new symptoms cirrhotic patient manifested some neurological signs, hep

atic encephalopathy should be highly suspected

chest pain lasted unusually and more severely than previous episodes （发作） of angina, myocardial infarction should be suspected

History of present illnessHistory 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

History of present illnessHistory 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 one’s diagnosis

General condition during the course

it may also provide some useful information

Past medical historyPast medical history

The past medical history consists of the overall assessment of the patient’s 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

Past medical historyPast 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

Review of systemsReview 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

Review of systemsReview 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”

Review of systemsReview 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

Review of systemsReview 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

Review of systemsReview 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

Review of systemsReview of systems

Hematological system

pallor yellow skin petechia purpura ecchymosis hematoma

Endocrinological system and metabolite

weakness profound sweating

abnormal appetite weight change

Review of systemsReview 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

Review of systemsReview 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 symp

toms/signs is elicited

Personal historyPersonal history

Social experiences

birth place

living area and duration particularly those epidemical areas

education living condition hobbyProfession and working place/conditionHabit smoking (amount and duration)

anesthetic drug （麻醉药）

Unhealthy sexual historyUnhealthy sexual history

Unhealthy sexual history:

Sexually transmitted disease

Marital historyMarital history

Marital history:

single or married

age of marriage

heath condition of partner

Menstrual historyMenstrual history

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

Family historyFamily 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

Skill and methods in inquireSkill and methods in inquire

Getting started

The narrative （叙述）

The closing

Getting startedGetting started

The diagnostic process begins at the first moment of meeting

One should be dressed appropriately, wearing a white coat with one’s 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

Getting startedGetting 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

Getting startedGetting 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 patient’s chief complaint or the problem that is regarded as paramount （极为重要的）

Getting startedGetting started

If the patient says “Haven’t you read my records?”

It is correct to say “No, I’ve 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

The narrativeThe narrative

Novice （初学者） interviewers are often worried about remembering the patient’s 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

The narrativeThe 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

The narrativeThe 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

The narrativeThe narrative

Overdirection is to be avoided, because this stifles the interview and prevents important points from being clarified

When patients use vague （含糊的） terms （术语） such as “often”, “a little”, “sometimes”, the interviewer must always for clarification, ask “What does ‘sometimes’ mean?” or “How often is ‘often’?”

The narrativeThe narrative

The interviewer should be alert （警觉） for subtle clues from the patient to guide the interview further

There are a variety of technique to encourage and sustain the narrative

The closingThe 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 patient’s past medical history

If any part of the history needs clarification, this is the time to obtain it

The closingThe 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

Basic interviewing techniquesBasic interviewing techniques

Questioning （询问）Silence ( 沉默 )Facilitation （简单化）Confrontation （面对面）Interpretation （解释）Reflection （反省 )Support ( 支持 )

QuestioningQuestioning

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

Open-ended questioningOpen-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

Direct questioningDirect 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

Direct questioningDirect 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

Direct questioningDirect 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

Direct questioningDirect 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?

Direct questioningDirect 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?

Direct questioningDirect 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?

Direct questioningDirect 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?

Direct questioningDirect questioning

Associated manifestation

Do you ever have nausea with the pain?

Have you noticed other changes that happen when you start to sweat?

O-P-Q-R-S-TO-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

Question types to avoidQuestion 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?”

Question types to avoidQuestion types to avoid

Why question It carries tones of accusation ( 谴责 ) This type of question almost always asks a patient to 阿

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 reaso

n…?”

Question types to avoidQuestion 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?”

Question types to avoidQuestion types to avoid

Medical jargon( 行话 ) “You seem to have a homonymous （同侧） hemianops

ia( 偏盲）”

Leading question or biased question It carries a suggestion of the kind of response the intervie

wer is looking for

Always ask questions in the positive, not the negative “You don’t have diabetes, do you?” it should be “Do you have diabetes?”