The Calgary-Cambridge Guide to the Medical Interview - Gathering Information on the Biomedical History: Difference between revisions
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To avoid side-tracking, it's recommended to use a history taking framework that could help you to structure your history taking process and go through the important questions in an orderly and organized way. | To avoid side-tracking, it's recommended to use a history taking framework that could help you to structure your history taking process and go through the important questions in an orderly and organized way. | ||
The gaining of biomedical information is regarded as the core of the medical assessment process by many. Although information gathered is imperative for the formation of a sound hypothesis, the clinical significance of psychosocial factors should not be overlooked. It is recommended to follow a function-based approach in the investigation of biomedical information in order to ensure patient centred care. Throughout the gaining of information, dynamic clinical reasoning is necessary to develop relevant hypotheses, select the appropriate assessment techniques, formulate a sound diagnosis and ensure a comprehensive and applicable management plan. | |||
== Hypothesis generation and clinical reasoning == | == Hypothesis generation and clinical reasoning == | ||
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The mnemonic PQRST<ref>Estes ME. Health assessment and physical examination. Cengage Learning; 2013 Feb 25.</ref> is a framework developed to be used in information gathering: | The mnemonic PQRST<ref>Estes ME. Health assessment and physical examination. Cengage Learning; 2013 Feb 25.</ref> is a framework developed to be used in information gathering: | ||
* '''''Palliation/provocation''''' refers to any factors that may exacerbate/aggravate or improve symptoms. It can provide valuable information on the nature and causes of the symptoms. It could be specific movements, emotional state, or overload that contribute to the symptoms<ref name=":5">Butler RK, Finn DP. Stress-induced analgesia. Progress in neurobiology. 2009 Jul 1;88(3):184-202.</ref><ref name=":6">Fava GA, McEwen BS, Guidi J, Gostoli S, Offidani E, Sonino N. Clinical characterization of allostatic overload. Psychoneuroendocrinology. 2019 Oct 1;108:94-101.</ref>. | * '''''Palliation/provocation''''' refers to any factors that may exacerbate/aggravate or improve symptoms. It can provide valuable information on the nature and causes of the symptoms. It could be specific movements, emotional state, or overload that contribute to the symptoms<ref name=":5">Butler RK, Finn DP. Stress-induced analgesia. Progress in neurobiology. 2009 Jul 1;88(3):184-202.</ref><ref name=":6">Fava GA, McEwen BS, Guidi J, Gostoli S, Offidani E, Sonino N. Clinical characterization of allostatic overload. Psychoneuroendocrinology. 2019 Oct 1;108:94-101.</ref>. | ||
* '''''Quality''''' '''of symptoms:''' also refers to the type or nature of symptoms. this involves the patient's perception of the presenting symptoms which could give clues on the etiology of the consition<ref name=":0" />. Example of questions: “what type of pain is it?” or “Is it a sharp pain, or burning? Or a dull ache?” or “Would you say your cough is dry or wet? Maybe wheezy, or barking?”)<ref>Fourie M. Gathering Information - Underpinning Biomedical History. Phsyioplus Course 2020 </ref> | * '''''Quality''''' '''of symptoms:''' also refers to the type or nature of symptoms. this involves the patient's perception of the presenting symptoms which could give clues on the etiology of the consition<ref name=":0" />. Example of questions: “what type of pain is it?” or “Is it a sharp pain, or burning? Or a dull ache?” or “Would you say your cough is dry or wet? Maybe wheezy, or barking?”)<ref name=":7">Fourie M. Gathering Information - Underpinning Biomedical History. Phsyioplus Course 2020 </ref> | ||
* '''''Region/Radiation''''' a body chart aids to conceptualise symptoms and assists the therapist to recognize potential patterns that may be specific to certain conditions. | * '''''Region/Radiation''''' a body chart aids to conceptualise symptoms and assists the therapist to recognize potential patterns that may be specific to certain conditions. | ||
* '''''Severity''''': different scales and outcome measures could be used such as the VAS, the Disability of Arm, Shoulder and Hand (DASH) questionnaire, or the Dizziness Handicap Inventory (DHI). | * '''''Severity''''': different scales and outcome measures could be used such as the VAS, the Disability of Arm, Shoulder and Hand (DASH) questionnaire, or the Dizziness Handicap Inventory (DHI). | ||
| Line 64: | Line 66: | ||
=== Current Medical History === | === Current Medical History === | ||
The prevalence of chronic | Asking questions in regards with: | ||
* The prevalence of chronic conditions | |||
* Medications: consider the duration of use of medications and their side effects | |||
* General health including habits such as smoking, alcohol, drug use, diet, sleep, exercises, activities, and preventive health measures such as screening and immunization | |||
It's important here to remain objective, sensitive, and respectful at all times as patients often feel ashamed or stigmatized for certain conditions or medicinal uses. Create a safe, non-judgmental space when assessing these, since patients are often reluctant to share this type of information with health-care professionals<ref name=":7" />. | |||
=== Previous medical history === | === Previous medical history === | ||
Although might seem irrelevant, physical trauma, hospitalization, or injuries throughout the patient’s lifetime should be enquired<ref name=":7" />. | |||
=== Family history === | === Family history === | ||
To exclude the possibility of any link to genetic or hereditary diseases, the family history of the previous two generations should be visited during the information gathering process. Counseling on preventative screening should be advised when hereditary disease is found<ref name=":0" />. | |||
=== Review of the systems === | === Review of the systems === | ||
In an ideal world, a complete head-to-toe checkup gives a comprehensive image of the patient's condition, however, this process wouldn't be appropriate for most clinical settings with limited time. A decision is made based on good judgment and clinical reasoning on which system review to include in the assessment. | |||
This table provides a summary of additional somatic systems to consider in the assessment<ref name=":7" />. It is important to explain to the patients why other systems than that of the presenting pathology are investigated to prevent unnecessary anxiety<ref name=":0" />. | |||
{| class="wikitable" | {| class="wikitable" | ||
|+ | |+ | ||
!SYSTEM | !SYSTEM | ||
!FACTORS TO CONSIDER | !FACTORS TO CONSIDER | ||
| Line 86: | Line 94: | ||
|- | |- | ||
|Respiratory | |Respiratory | ||
|Breathing problems, coughing, wheezing, sputum production, allergic rhinitis, chronic sinusitis, | |Breathing problems, coughing, wheezing, sputum production, allergic rhinitis, chronic sinusitis, earache hearing loss | ||
|- | |- | ||
|Cardiac | |Cardiac | ||
| Line 102: | Line 110: | ||
|Neurological | |Neurological | ||
|Numbness, tingling, tremors, weakness, coordination, balance | |Numbness, tingling, tremors, weakness, coordination, balance | ||
|} | |} | ||
== References == | == References == | ||
Revision as of 00:08, 10 November 2020
What is meant by gathering information?[edit | edit source]
The history-taking or information-gathering session form an essential skill of the healthcare practice that assists in the diagnosis of the patient's physical problems. The success of such a process relies on many factors including; preparation, planning, and communication between the healthcare professional and the patient[1]. During the consultation, the physiotherapist or other healthcare practitioner aims to gather the information they need to interpret and understand the nature of the symptoms and how patients are coping with them[2]. Accurate information account for 80% of what is needed to diagnose a condition [3]
| Taking a patient history is like playing detective, ‘searching for clues, collecting information without bias, yet staying on track to solve the puzzle’ [2] |
|---|
Active listening is considered to be the most fundamental communication skill required for a successful consultation which involves verbal and non-verbal behaviors. The non-verbal behaviors are summarized in the SOLER framework:
- sitting Square on to the patient
- Open position
- Leaning slightly forward
- Eye contact
- Relaxed posture
The verbal elements of active listening are appropriate questioning techniques and summarising and recalling the history back to the patient[2]
Ask your patient active questions to encourage them to give you more about their condition and avoid closed questions that are answered with 'yes' or 'no'.
Summarising or recalling history is a dynamic process in which the patient has the opportunity to clarify, add, or correct the information[4].
To avoid side-tracking, it's recommended to use a history taking framework that could help you to structure your history taking process and go through the important questions in an orderly and organized way.
The gaining of biomedical information is regarded as the core of the medical assessment process by many. Although information gathered is imperative for the formation of a sound hypothesis, the clinical significance of psychosocial factors should not be overlooked. It is recommended to follow a function-based approach in the investigation of biomedical information in order to ensure patient centred care. Throughout the gaining of information, dynamic clinical reasoning is necessary to develop relevant hypotheses, select the appropriate assessment techniques, formulate a sound diagnosis and ensure a comprehensive and applicable management plan.
Hypothesis generation and clinical reasoning[edit | edit source]
A sound hypothesis depends on good quality clinical reasoning, using as much as possible clinically relevant information gained during the patient interview. Clinical reasoning is defined as a process of analysing acquired clinical data in combination with patient preferences, professional judgement and scientific knowledge, with the goal of structuring meaning, developing objectives and implementing health management strategies in the management of a patient[5]. Physiotherapists often apply clinical reasoning to arrive at a working hypothesis by utilising either a hypothetico-deductive model, or pattern recognition, or a combination of the two. In a hypothetico-deductive model, hypotheses are generated from all observations, after which clinical data gained is tested to arrive at the most likely hypothesis. Pattern recognition, generally used by more experienced therapists, involve the formation of a hypothesis from typical symptom and disease presentation noted, and subsequent data exploration to confirm or negate the hypotheses[6].
The use of a function and disability model can help the therapist to better understand the context of the presenting patient during the process of clinical reasoning and hypothesis generation. It aids to organize information in a practical and logical manner, while also integrating environmental, social and psychological factors in the understanding of the person and condition[5]. Furthermore, the use of a function and disability model as outcome measure allows to standardise patient impairment and provides a concrete, comparable benchmark by which to measure effect of management. The International Classification of Function, Disability and Health (ICF) will be discussed as a function and disability model underpinning clinical reasoning and hypothesis generation.
Information gathering in the context of the International Classification of Function, Disability and Health (ICF)[edit | edit source]
The ICF is a classification system which describes the different components of functioning of a person with any health condition. It was approved by the World Health Organisation (WHO) in 2001 as universally accepted conceptual model and taxonomy of human functioning. The ICF describes human functioning as an interaction between body functions and structures, activities, and participation, together with the effect of psychological and environmental influences (Figure 1). The model is built on biopsychosocial principles which regards the patient as a holistic, psychological being within a specific environment. Disability is described according to impairment of body functions/structure, limitations in activities and restrictions in participation[7].
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The term body functioning and structures refers to physiological processes and anatomic structures, and any abnormality to these is referred to as an impairment. Examples of impairments include arterial fibrillation leading to physical weakness and fatigue, or ulnar nerve entrapment leading to forearm pain. Activity refers to execution of tasks or actions and represents the individual’s perception of function. Examples of activities include walking/running, grasping, kicking or carrying. Inability to perform normal activities is referred to as limitations. Participation refers to life situations in which an individual is actively involved. Inability to engage in normal participation is called participation restrictions. Examples are playing soccer, preparing food, looking after children or visiting the shops[7]. Environmental and personal factors are collectively known as contextual factors, and refer to the influence of surroundings, psychology and experience of illness on the patient’s health[8].
From a biopsychosocial point of view, the ICF is a model for standardisation of function and health which allows for comparison across the spectrum of disability. The inclusion of contextual factors provides a patient-specific representation of function which illustrates why different individuals may be differently affected by a seemingly similar pathology. For example, one patient may walk on a fractured metatarsal for days before having it diagnosed, where another patient with similar biomedical factors and who sustained a similar injury may be in much more distress soon after onset of injury. Differences in contextual factors may also influence recovery and behaviour of the individual[8].
Although physiotherapists often successfully treat patients who reach full recovery, we should remember that many conditions are chronic and progressive in nature and that some patients will never be completely asymptomatic (Parkinson’s disease or cystic fibrosis, for example). For this reason, the focus should be on rehabilitation as a process to help patients reach their optimal physical, psychological, social, occupational and educational potential within the anatomical and physiological capacity available[9]. The ICF aids rehabilitation professionals to gauge the functional capacity of a patient, analyse the source of restrictions and limitations and compile a realistic management plan accordingly.
The consideration of the ICF in the medical interview helps rehabilitation professionals to understand the impact of a health condition on the patient’s functionality and well-being. Emphasis is placed on the functional limitation due to presenting symptoms, instead of only focusing on the specific presentation and behaviour of symptoms. Proper comprehension of the bigger context of ill-health will also assist the therapist in realistic goal setting and provide better understanding of the patient as a person, as well as his/her experience of the condition and the potential role this experience can play in symptom presentation and/or recovery. Knowledge of a patient’s functional impairment will furthermore assist the therapist to select assessment techniques based on symptom-eliciting functional movements. For this reason, it is strongly recommended that the process of information gathering should be based on the patient’s current functional capacity and the potential effect of the presenting condition/symptoms.
Gaining biomedical information[edit | edit source]
The specific investigation of biomedical history is highly dependent upon the subspecialty of medicine/allied health involved[10]. A women’s health physiotherapist will have a different investigation approach and special questions to a neuropediatric physiotherapist, for example. The basic principles of most biomedical information to be gathered remains the same across the spectrum, however, and for the purpose of this document, a number of these will be discussed in more detail. These factors include the behaviour of symptoms, red flags, medical history, and a review of relevant systems[2].
Red flags[edit | edit source]
Red flags are any signs or symptoms that may indicate a possible serious underlying condition, that warrants further medical assessment and/or intervention[11] before continuing with therapeutic management. Although the concept of red flags covers all areas of medicine, specific subspecialties need to assess specific red flags relevant to their field. For example, musculoskeletal physiotherapists treating a lumber condition should clear any signs of cauda equina syndrome and spinal stenosis, and for upper cervical pain/headache and vertigo, vertebrobasilar insufficiency and cervical spine instability should be excluded.
When screening for red flags, is it suggested for the therapist to inform the patient that the relevant questions are only asked to ensure that no potential underlying pathologies are missed. Also confirm that the prevalence of red flags is mostly low in the general population. This will put potentially catastrophizing patients at ease and prevent unnecessary anxiety regarding questions that may seem irrelevant to the condition. When red flags are indeed identified, share your findings with the patient in a logical manner using easily understandable language, and explain that referral to a specialist is necessary to exclude underlying pathology before continuing with therapy.
Information gathering: a step by step guide[edit | edit source]
Presenting symptoms[edit | edit source]
A good place to start from when taking history is to explore what is the most concerning problem of the patient.
A patient-centered approach investigates the patients’ ideas and concerns about their symptoms and their expectations[4]. The majority of patients will not show how anxious they are about their condition thus it's important to ask about what they think about their symptoms to understand how they think and discuss their concerns and fears.
The mnemonic PQRST[12] is a framework developed to be used in information gathering:
- Palliation/provocation refers to any factors that may exacerbate/aggravate or improve symptoms. It can provide valuable information on the nature and causes of the symptoms. It could be specific movements, emotional state, or overload that contribute to the symptoms[13][14].
- Quality of symptoms: also refers to the type or nature of symptoms. this involves the patient's perception of the presenting symptoms which could give clues on the etiology of the consition[2]. Example of questions: “what type of pain is it?” or “Is it a sharp pain, or burning? Or a dull ache?” or “Would you say your cough is dry or wet? Maybe wheezy, or barking?”)[15]
- Region/Radiation a body chart aids to conceptualise symptoms and assists the therapist to recognize potential patterns that may be specific to certain conditions.
- Severity: different scales and outcome measures could be used such as the VAS, the Disability of Arm, Shoulder and Hand (DASH) questionnaire, or the Dizziness Handicap Inventory (DHI).
- Timing: refers to 1- a timeline from onset to the current presentation should be established, including further exploration of mechanisms, and any regression/progression of the condition since onset. 2- Any 24-hour pattern, for example, worse at night, or stiffness and pain first thing in the morning. 3- frequency of symptoms i.e. intermittent or constant.
Current Medical History[edit | edit source]
Asking questions in regards with:
- The prevalence of chronic conditions
- Medications: consider the duration of use of medications and their side effects
- General health including habits such as smoking, alcohol, drug use, diet, sleep, exercises, activities, and preventive health measures such as screening and immunization
It's important here to remain objective, sensitive, and respectful at all times as patients often feel ashamed or stigmatized for certain conditions or medicinal uses. Create a safe, non-judgmental space when assessing these, since patients are often reluctant to share this type of information with health-care professionals[15].
Previous medical history[edit | edit source]
Although might seem irrelevant, physical trauma, hospitalization, or injuries throughout the patient’s lifetime should be enquired[15].
Family history[edit | edit source]
To exclude the possibility of any link to genetic or hereditary diseases, the family history of the previous two generations should be visited during the information gathering process. Counseling on preventative screening should be advised when hereditary disease is found[2].
Review of the systems[edit | edit source]
In an ideal world, a complete head-to-toe checkup gives a comprehensive image of the patient's condition, however, this process wouldn't be appropriate for most clinical settings with limited time. A decision is made based on good judgment and clinical reasoning on which system review to include in the assessment.
This table provides a summary of additional somatic systems to consider in the assessment[15]. It is important to explain to the patients why other systems than that of the presenting pathology are investigated to prevent unnecessary anxiety[2].
| SYSTEM | FACTORS TO CONSIDER |
|---|---|
| Head | Dizziness, headaches, faintness, recent head injury |
| Eyes | Any changes in vision, regular optometric tests |
| Respiratory | Breathing problems, coughing, wheezing, sputum production, allergic rhinitis, chronic sinusitis, earache hearing loss |
| Cardiac | Anemia, hypertension, palpitations |
| Gastrointestinal | Heartburn, irritable bowel syndrome, nausea, changes in regular toileting routine |
| Urogenital/gynaecological | Pain with urination, menstruation-related symptoms, changes in regular toileting routine |
| Muskuloskeletal | Stiffness, cramps, weakness, swelling |
| Neurological | Numbness, tingling, tremors, weakness, coordination, balance |
References[edit | edit source]
- ↑ Gask L, Usherwood T. The consultation. Bmj. 2002 Jun 29;324(7353):1567-9.
- ↑ 2.0 2.1 2.2 2.3 2.4 2.5 2.6 Kaufman G. Patient assessment: effective consultation and history taking. Nursing Standard. 2008 Oct 1;23(4). Cite error: Invalid
<ref>tag; name ":0" defined multiple times with different content - ↑ Epstein O, Perkin GD, Cookson J, Watt IS, Rakhit R, Robins AW, Hornett GA. Clinical Examination E-Book. Elsevier Health Sciences; 2008 Jul 7.
- ↑ 4.0 4.1 Moulton L. The naked consultation: A practical guide to primary care consultation skills. CRC Press; 2017 Jul 14.
- ↑ 5.0 5.1 Jones, M., Edwards, I., Gifford, L., 2002. Conceptual models for implementing biopsychosocial theory in clinical practice. Man. Ther. 7, 2–9. https://doi.org/10.1054/math.2001.0426
- ↑ Jones, M.A., 1992. Clinical Reasoning in Manual Therapy. Phys. Ther. 72, 875–884. https://doi.org/10.1093/ptj/72.12.875
- ↑ 7.0 7.1 Stucki, G., Cieza, A., Melvin, J., 2007. The International Classification of Functioning, Disability and Health (ICF): a unifying model for the conceptual description of the rehabilitation strategy. J. Rehabil. Med. 39, 279–285. https://doi.org/10.2340/16501977-0041
- ↑ 8.0 8.1 Johnston, M., Dixon, D., 2014. Developing an integrated biomedical and behavioural theory of functioning and disability: adding models of behaviour to the ICF framework. Health Psychol. Rev. 8, 381–403. https://doi.org/10.1080/17437199.2013.855592
- ↑ Heerkens, Y., Hendriks, E., Oostendorp, R., 2006. Assessment instruments and the ICF in rehabilitation and physiotherapy. Med. Rehabil. 10, 1–14.
- ↑ Johnson, P., Rain, S., Meadows, L., Lynch-Ellerington, M., 2009. Assessment and Clinical Reasoning in the Bobath Concept, in: Bobath Concept: Theory and Clinical Practice in Neurological Rehabilitation. Blackwill Publishing Ltd, pp. 43–63.
- ↑ Briggs, A.M., Fary, R.E., Slater, H., Ranelli, S., Chan, M., 2013. Physiotherapy co-management of rheumatoid arthritis: Identification of red flags, significance to clinical practice and management pathways. Man. Ther. 18, 583–587. https://doi.org/10.1016/j.math.2013.01.006
- ↑ Estes ME. Health assessment and physical examination. Cengage Learning; 2013 Feb 25.
- ↑ Butler RK, Finn DP. Stress-induced analgesia. Progress in neurobiology. 2009 Jul 1;88(3):184-202.
- ↑ Fava GA, McEwen BS, Guidi J, Gostoli S, Offidani E, Sonino N. Clinical characterization of allostatic overload. Psychoneuroendocrinology. 2019 Oct 1;108:94-101.
- ↑ 15.0 15.1 15.2 15.3 Fourie M. Gathering Information - Underpinning Biomedical History. Phsyioplus Course 2020
