How to ask

The patient needs to understand what is being said. Generally speaking, technical terms are best avoided. The

MACLEOD'S CLINICAL EXAMINATION

TABLE 1.3 Elements in a clinical history

Presenting complaint

Past medical history

Drug history

Family history

Social history

Systemic or general symptom inquiry

Further information from a third party

Alternative order

Past medical history

Presenting complaint

Systemic inquiry

Drug history

Family history

Social history

Further information from a third party

TABLE 1A Examples of inquiry techniques jiuhlic is becoming increasingly informed on medical mailers through the Internet and mass media, bill their use of medical jargon does nol necessarily mean they understand the terms. Similarly there are terms such as 'shock*, 'stress', "nervous breakdown' and 'gastric flu' which need to be clarified, if used by the patient.

There are two main types of inquiry - open and closed (Table ] .4).

• Open inquiries arc generally 'how', 'what', 'why' questions: 'tell nie about' inquiries. Such questions give

TABLE 1A Examples of inquiry techniques

Open inquiries

Tell me about your pain

What effects has this illness had on your life?

What happened next?

How did you read to that tragedy?

Closed inquiries

When did your headache begin?

Have you had chest pain?

Has anyone in your family had a simitar problem?

Do you smoke? If so, how many cigarettes per day?

Remember- phrasing inquiries as open questions extracts more information and is to be preferred, e.g. 'what effect did painkillers have"7' is a better question than 'did painkillers ease the headache?

patients the opportunity to say what they want to say. and to tell the doctor the history as they perceive it, • Closed enquiries are generally 'who", 'when', 'where' questions: 'is it or is ii not' inquiries. They arc mainly used to expand the patient's story and to clarify specific points.

History-taking normally begins with open questions to establish the nature of the presenting problem or problems. Only then is it appropriate to introduce more closed inquiries as the doctor focuses on the problem to establish facts and details. As ibe information is collected some

Top iayer

Deepest layer

Focus

Free narration about PC

Establishing the clinical features of the PC

Potentially associated symptoms or complaints

Subjective experience; effects on lifestyle and emotion

Patient's understanding, attitudes and wishes

Clinical purpose/approach

Facilitation

Closed inquiries, clarification, reflection

Encompassing and excluding diagnoses t

Assessing Illness impact

Preparing for explanation and management

Fig, f ,5 Example of nests and layers in history-taking.

diagnostic possibilities are discounted while others lire raised. This processing leads to inquiries which involve clarification, reflection and summary, all techniques to be used selectively.

* Clarification enables the clinician and the patient to resolve apparent contradictions, ambiguities and uncertainties in the history.

Sometimes these issues arise because clinicians' questions have been confusing. On other occasions, apparent contradictions occur because the patient is acutely ill or in severe pain. Sometimes contradictions in the history should alert the clinician to the possibility that the patient is either confused or dementing.

As a principle, the clinician should seek to clarify the history as tactfully as possible. For example, not infrequently patients may say that they do not have a cough but then describe their sputum. Rather than confront them with this paradox, the clinician should resolve the uncertainty by asking further specific questions regarding the nature of the sputum. Rarely it may be appropriate to challenge the patient's story: 'You mention that you only drink fifteen pints of beer in a week, but tell me that you spend between £60-£K0 011 alcohol every week. How does this add up?'

* Reflection involves putting back to the patient a symptom or remark the patient has provided either for confirmation or development. This also emphasises a matter of importance,

"You said that you developed a tingling sensation in your arms after you became light-headed. Can you lell me anything more about these symptoms?'

* Summary is an expansion of reflection, in which chunks of history arc condensed and reiterated for the patient to confirm and correct.

'Let's see if I've got this right - and please correct me if I'm wrong. You were fine until 8 o'clock this morning when you suddenly developed severe, crushing pain in the centre of your chest while you were in the toilet. You felt sick but didn't vomit, you felt cold and sweaty and became breathless. You thought you were about to die; your wife dialled 999.'

KEY POINTS

• History-taking involves knowing what to ask and how to ask it.

• How inquiries are framed largely determines the information elicited. Open-ended questions are better than closed questions in establishing the framework of the history. Closed questions provide detail and sharpen the account.

• Avoid using technical terms which the patient may not understand.

• Techniques such as clarification, reflection and summary should be used when and where appropriate.

These techniques can be used to facilitate rapport, building up the doctor- patient relationship through the demonstration of attentive listening.

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