Historytaking

Taking a history from a patient may pose problems for a variety of reasons. This is rarely the patient's fault: it is necessary to bear this firmly in mind and remain objective and professional throughout what may be a protracted and less than productive interview.

Patient too unwell (triage, severe pain, profuse bleeding, vomiting, severe breathlessness, agitation or distress)

Principles:

* Rapidly assess the situation.

a Treat the patient.

• Obtain history from third party.

• Review in detail when the patient is fit enough.

Mental incapacity (coma, confusion, acute psychosis, severe learning disability)

Principles:

m Ascertain what, if any, history can be obtained from the patient.

• Seek history from a third party or third parties relatives, neighbours, friends or professionals. Establish the basis of their knowledge of the patient through how long, how often and how recently they have had contact.

Communication difficulties

No English language (foreign visitors, members of an ethnic minority).

Principles:

• Establish competence to understand and express English

- it is not uncommon for people to understand considerably more than they can express.

• If accompanied, ask whether the friend or relative could and would act as interpreter, Proceed if the patient agrees to this.

• If alone, or involving a friend or relative is unacceptable or inappropriate, seek an interpreter (most clinicians have access to a translator service. Occasionally an Embassy has to be approached).

Sensory deficit (deafness, mutism). Principles:

• Check the hearing aid is working.

• Establish a means of communication. Tins may involve:

- obtaining a history through written questions lip reading

- involving a relative who is acceptable and can communicate with the patient

- involving someone who is proficient in sign language (may be a staff member, or volunteer).

Expressive problem (dysphasia, dysarthria, stammering). Principles:

• Establish the nature of the problem.

• If the patient understands, then agree with the paiieni how best to proceed, e.g. could involve the patient communicating in writing, or via a relative.

• If the patient cannot understand, then proceed as for mentally incapacitated.

Emotionally disordered (angry or abusive/threatening). Principles:

a Ascertain the nature of the problem and try to establish

MACLEOD'S CLINICAL EXAMINATION

the basis for the patient's reaction: 'I get the impression that you are angry. Can you tell tne why?'

• Encourage patients to talk through the problem from their perspective, even at the expense of interrupting the history-taking. The problem may involve a previous unsatisfactory medical consultation or a misunderstanding arising during the currcnt one.

• Try to correct any misunderstanding, apologising if appropriate.

• Set limits. Abuse, threats or violence may be understandable but are unacceptable reactions which arc counterproductive. II the problem remains unresolved, consider terminating the interview and offering an alternative appointment.

During, or before a hospital consultation, it is frequently useful to contact the patient's family practitioner, not just to obtain or verify the medical history, but to establish how the communication problem has been managed in ihe primary care setting. Ideally this information should be obtained before the patient and family are interviewed.

Consultations that involve a third person present special problems in terms of maintaining palient confidentiality. This is why. whenever possible, the clinician should establish the patient's agreement with this arrangement. Potentially sensitive areas of the history should not be broached unless it is clinically imperative, the third party is acceptablc and the patient is given warning and choice before proceeding.

Rapport is often impaired when an intermediary is required to establish a communication link between clinician and patient, The doctor can improve matters, however, by increasing the emphasis on nonverbal communication -greater eye contact, more smiles and encouraging nods -and making a point of directing inquiries to the patient rather than to the intermediary.

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