Sunday, February 06, 2005

Mad House mAdschool: Patient Evaluation

Interviewing is the exchange of relevant information about the patient for the interviewer's professional purposes. It is the premier skill in medicine; it is the vehicle for the physician-patient interaction in virtually all circumstances, through which is derived most of the information about an individual patient.

History Taking is the most important part of the interview. often, I meet patients under the impression that a physical or an expensive test is going to make the diagnosis. It can, but more often, the tests and physical exam are used to confirm a diagnosis or differentiate between a number of suspicions. The history portion of the meeting accounts for nearly 90% of the information learned. The physical and tests account for the other 10%.

How should a good history be performed?

Nearly everyone agrees that a good history often takes the form of any other good interview. Meaning, start generally and become more focused. A good opening line is "What brought you to the hospital today?". Some patients may answer "The ambulance". Let this not deter you.

Once you have an actual complaint (ie: Chest pain), and REALLY try to nail down ONE complaint, then continue asking more generalized questions about the pain and focus more narrowly in follow up questions to pin down a hypothesis.

Patients often don't realize that any one complaint can have a multitude of causes. For example, chest pain can range from a fulll blown heart attack with deadly consequences to heart burn or just a muscle spasm. Off the top of my head I can name 15 causes of chest pain right now and I'm just second year resident. I will not get more specific here because chest pain should always be evaluated by a doctor. ALWAYS!

Any standard questions?

Sure. Every history usually includes list of medications. So remember yours or bring a list (ie: white pill this big means absolutely nothing to us. Do you know how many white pills this big there are?).

Every history includes allergies, social history (smoking, alcohol, drugs, type of work) and if the practitioner is really good he will ask a sexual history (This is the sign of a GOOD doctor, do not be offended).

Any trick questions?

Well, sort of. I like to ask some questions that may be misleading. For example I often ask how much alcohol a patient drinks? Sometimes I get "Just a little" as a response, or some variation. My follow up is usually "One six pack or two?" I ask this as if its common practice to drink two six packs a day. It's happened many times that I get a yes, or something like "Naaaa..not two six packs, that's too much, just 5 or 6 beers". FIVE OR SIX beers, aha. In my neck of the woods the follow up to that is "The big cans or the small ones?". You don't want to know.

There are different theories on the technique best utilized for interviewing. Mostly, everybody has their own style, some better than others. Medicine, you'll find, is a science applied through experience perfected art.