Taking the Clinical History

ABOUT THIS BOOK

In an era of ever-increasing dependence upon technology, physicians are losing the basic skills of patient examination and taking the medical history. This book describes the scenario in which the physician sits down with a patient to elicit a medical history. For example, how to greet a patient, how to discover the patient's chief concern, how to elicit symptoms, how to manage feelings as the patient and physician interact, and how to choose topics to explore, and use the appropriate word selection, phrasing, and tone of voice. A good history leads to trust and rapport, and also to the determination of the best management of the patient's condition. Dr. William DeMeyer, a well-known physician and author of the major text on the neurologic exam, describes how to take a medical history, and also explains the reasons why it is done in a particular way. The author reviews the actual questions that a health provider should ask and the responses to a patient's answers. More importantly, the author describes how to listen to the patient's real needs as a person, rather than just a repository of symptoms.

TABLE OF CONTENTS

1: OUTLINE OF THE CLINICAL HISTORY
Definition and Scope of the Clinical History
Detailed Outline of the Clinical History

2: BASIC DEFINITIONS: DISEASE, SYMPTOMS, SIGNS, SYNDROMES, AND DIAGNOSIS
I. What is Disease?
II. Manifestation of Disease by Symptoms and Signs
III. Diagnosis and Differential Diagnosis of Disease
IV. Summary

3: THE IMPORTANCE OF THE CLINICAL HISTORY
I. Why the Clinical History is the Most Important Event in the Practice of Medicine
II. The Clinical History as a Mutual Process of Knowing between the Physician and the Patient
III. The History is the Only Way to Diagnose the Many Diseases that Produce Only Symptoms but no Signs
IV. How the History Focuses the Physical Examination
V. Why No Physical or Laboratory Finding Has Meaning Until Integrated with the Patient's Full Clinical History
VI. How the History Provides the Basis for Public Health Policy
VII. Summary

4: HOW THE PHYSICIAN'S ETHICS AND GOALS DETERMINE THE CONTENT AND TECHNIQUES OF THE CLINICAL HISTORY
I. The Ethical and Operational Components of the Medical Model for the Patient-Physician Relationship
II. Origin of the Ethical Code for the Practice of Medicine
III. How Each Ethic of the Medical Model Shapes the History
IV. Replacing Social Responses with Professional Responses
V. The Atcual Operational Steps of the Medical Model for the Practice of Medicine
VII. Beyond the Consulting Room
VIII. Summary

5: PRIVACY: THE SETTING AND THE APPAREL FOR AN OPTIMUM CLINICAL HISTORY
I. Privacy and the Private Interview
II. The Room Design for the Medical Interview
III. Personal Attributes of the Physician
IV. Use of the Telephone and Telemedicine
V. Summary

6: THE PATIENT'S CHIEF CONCERN AND PRESENT ILLNESS
I. The Initial Contact and the Face Sheet
II. Format for the Clinical History
III. Technique for Meeting the Patient
IV. THe Patient's Chief or Presenting Concern
V. Listening: The Essential Technique of the Clinical History
VI. Technique for Eliciting the PResenting Concern and Current Illness
VII. Historical Analysis of Recurrent Attacks that are Similar
VIII. Current Medications and Management
IX. Closing the Present Illness History in Preparation for the Past Clinical History
X. Summary

7: THE PAST CLINICAL HISTORY AND THE REVIEW OF SYSTEMS
I. Eliciting the Past Clinical History
II. The Review of Systems (ROS)
III. Visualize the Head and the Nervous System
IV. Next Visualize the Motor (Muscular) System
V. Next Visualize the Skeletal System
VI. Next Visualize the Bone Marrow
VII. Next Visualize the Chest and Its Contents and Start with the Respiratory System
VIII. Next Visualize the Cardiovascular System
IX. Next Visualize the Gastrointestinal System
X. Next Visualize the Renal System
XI. Next Visualize the Reproductive System
XII. Next Visualize the Endocrine System
XIII. Next Visualize the Immune and Lymphatic System
XIV. Finally Visualize the Skin
XV. Environmental/Toxic Exposure History
XVI. Supplementing the Standard History and Review of Systems with Inventories, Rating Scales, and Structured Interviews
XVII. Efficiency in the Review of Systems: The Long and Short of It
XVIII. Summary

8: THE FAMILY HISTORY
I. Transition to the Family History
II. Diagramming the Pedigree
III. Special Problems in the Family History of Pediatric Patients
IV. Summary

9: THE PSYCHOSOCIAL HISTORY AND MENTAL STATUS HISTORY
I Introduction to the Mental Status Examination
II. Quick (but effective) Overall Screening of the Patient for Mental Illness
III. Detailed Inquiries into the Patient's Mental Status
IV. The Sensorium or Sensorium Commune: Common Sense and Its Testing
V. An Ethics, Values, and Spiritual History
VI. Special Features of the History in Suspected Dementia
VII. A Historical Tutorial with Rufus of Epheseus
VIII. Summary

10: THE PREGNANCY AND DEVELOPMENTAL HISTORY (FOR PEDIATRIC PATIENTS)
I. Introduction to the Developmental History
II. Reproductive History
III. Labor and Delivery History
IV. Neonatal History
V. Classification of Infant Behaviors for Judging the Neurodevelopmental History and the Neurodevelopmental Examination
VI. Attending to the Mother's COncerns about her Infant's Development
VII. The Developmental History for Infants from Birth to Two Years of Age
VIII. The Developmental History for Children More than Two Years of Age
IX. Discussing Developmental Retardation with Parents
X. Summary

11: THE PREVENTIVE HISTORY AND WELLNESS
I. Importance of the Preventive History
II. Preventive History and Preventive Programs for Infants and Children
III. Preventive History and Preventive Programs for Teens and Adults
IV. Preventive History and Preventive Programs for Adults
V. The Positive Promotion of Wellness
VI. Summary

12: SUCCEEDING WITH THE DIFFICULT HISTORY
I. The Good and the Poor Historian
II. Causes for Difficult Histories and their Differential Diagnosis
III. Keeping the Difficult Patient on Track During the History
. IV. Emotional Interactions Between Patient and Physician that Results in a Diffcult History
. V. When It's a Question of Honesty or Accuracy of the History
. VI. When It's a Question of Irreconcilable Differences Between the Patient and the Physician
VII. Summary

13: ENDING THE CLINICAL HISTORY, RECORDING IT, AND INTEGRATING IT WITH THE PHYSICAL EXAMINATION
I. Three Questions to Close the History, Prior to the Physical Examination
II. Acquiring Additional History
III. Recording the Physical History
IV. Integrating the History and Physical Examination to Complete the Initial Medical Record
V. Integrating the History and Physical Examination, Illustrated by Analyzing the Commonest Sympton of All: Headaches
VI. Summary

14: THE HISTORY, APPROPRIATE MANAGEMENT, INFORMED CONSENT, AND PATIENT AUTONOMY
I. How the Same Techniques for the Clinical History Evaluate Patient Autonomy and Informed Consent
II. Interrelations of Appropriate Management, Informed Consent, and Patient Autonomy
III. Extending the History when the Patient Declines Appropriate Management
IV. How Promotion of Elective Cosmetic Surgery of Normal Tissues Biases the History
V. The Clinical History, Physician-Assisted Suicide, and Euthanasia
VI. The Clinical History, the Living Will, and Planning for Terminal Care
VII. An Example of How a Knowing Medical History Guided the Care of a Terminally Ill Patient
VIII. Best Examples of the Medical Model
IX. Summary
X. Epilogue: A Personal View

15: THE CLINICAL HISTORY OF THE MEDICAL MODEL COMPARED TO ALTERNATIVE MODELS
I. THe Science-based Clinical History
II. Definition of Alternative Medicine
III. Accomplishments of Physicians who Adhere to the Medical Model
IV. Epilogue

16: FOSTERING EMPATHY AND COMPASSION
I. Discovering the Patient's Personhood
II. Experiences in Compassion
III. Suggestions for Additional Sessions
IV. Feeling an Affinity for the Past of our Profession
V. Selected References for Comparison