Taking the Clinical History

by William DeMeyer, MD

Overview

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.

Product Details

ISBN-13:	9780195373776
Publisher:	Oxford University Press
Publication date:	04/02/2009
Pages:	368
Product dimensions:	5.40(w) x 8.20(h) x 0.90(d)

Table of Contents

CONTENTS1. OUTLINE OF THE CLINICAL HISTORYDefinition and Scope of the Clinical HistoryDetailed Outline of the Clinical History2. BASIC DEFINITIONS: DISEASE, SYMPTOMS, SIGNS, SYNDROMES, AND DIAGNOSISI. What is Disease? II. Manifestation of Disease by Symptoms and SignsIII. Diagnosis and Differential Diagnosis of DiseaseIV. Summary3. THE IMPORTANCE OF THE CLINICAL HISTORYI. Why the Clinical History is the Most Important Event in the Practice of MedicineII. The Clinical History as a Mutual Process of Knowing between the Physician and the PatientIII. The History is the Only Way to Diagnose the Many Diseases that Produce Only Symptoms but no SignsIV. How the History Focuses the Physical ExaminationV. Why No Physical or Laboratory Finding Has Meaning Until Integrated with the Patient's Full Clinical HistoryVI. How the History Provides the Basis for Public Health PolicyVII. Summary4. HOW THE PHYSICIAN'S ETHICS AND GOALS DETERMINE THE CONTENT AND TECHNIQUES OF THE CLINICAL HISTORYI. The Ethical and Operational Components of the Medical Model for the Patient-Physician RelationshipII. Origin of the Ethical Code for the Practice of MedicineIII. How Each Ethic of the Medical Model Shapes the HistoryIV. Replacing Social Responses with Professional ResponsesV. The Atcual Operational Steps of the Medical Model for the Practice of MedicineVII. Beyond the Consulting RoomVIII. Summary5. PRIVACY: THE SETTING AND THE APPAREL FOR AN OPTIMUM CLINICAL HISTORYI. Privacy and the Private InterviewII. The Room Design for the Medical InterviewIII. Personal Attributes of the PhysicianIV. Use of the Telephone and TelemedicineV. Summary6. THE PATIENT'S CHIEF CONCERN AND PRESENT ILLNESSI. The Initial Contact and the Face SheetII. Format for the Clinical HistoryIII. Technique for Meeting the PatientIV. THe Patient's Chief or Presenting ConcernV. Listening: The Essential Technique of the Clinical HistoryVI. Technique for Eliciting the PResenting Concern and Current IllnessVII. Historical Analysis of Recurrent Attacks that are SimilarVIII. Current Medications and ManagementIX. Closing the Present Illness History in Preparation for the Past Clinical HistoryX. Summary7. THE PAST CLINICAL HISTORY AND THE REVIEW OF SYSTEMSI. Eliciting the Past Clinical HistoryII. The Review of Systems (ROS)III. Visualize the Head and the Nervous SystemIV. Next Visualize the Motor (Muscular) SystemV. Next Visualize the Skeletal SystemVI. Next Visualize the Bone MarrowVII. Next Visualize the Chest and Its Contents and Start with the Respiratory SystemVIII. Next Visualize the Cardiovascular SystemIX. Next Visualize the Gastrointestinal SystemX. Next Visualize the Renal SystemXI. Next Visualize the Reproductive SystemXII. Next Visualize the Endocrine SystemXIII. Next Visualize the Immune and Lymphatic SystemXIV. Finally Visualize the SkinXV. Environmental/Toxic Exposure HistoryXVI. Supplementing the Standard History and Review of Systems with Inventories, Rating Scales, and Structured InterviewsXVII. Efficiency in the Review of Systems: The Long and Short of ItXVIII. Summary8. THE FAMILY HISTORYI. Transition to the Family HistoryII. Diagramming the PedigreeIII. Special Problems in the Family History of Pediatric PatientsIV. Summary9. THE PSYCHOSOCIAL HISTORY AND MENTAL STATUS HISTORYI Introduction to the Mental Status ExaminationII. Quick (but effective) Overall Screening of the Patient for Mental IllnessIII. Detailed Inquiries into the Patient's Mental StatusIV. The Sensorium or Sensorium Commune: Common Sense and Its TestingV. An Ethics, Values, and Spiritual HistoryVI. Special Features of the History in Suspected DementiaVII. A Historical Tutorial with Rufus of EpheseusVIII. Summary10. THE PREGNANCY AND DEVELOPMENTAL HISTORY (FOR PEDIATRIC PATIENTS)I. Introduction to the Developmental HistoryII. Reproductive HistoryIII. Labor and Delivery HistoryIV. Neonatal HistoryV. Classification of Infant Behaviors for Judging the Neurodevelopmental History and the Neurodevelopmental ExaminationVI. Attending to the Mother's COncerns about her Infant's DevelopmentVII. The Developmental History for Infants from Birth to Two Years of AgeVIII. The Developmental History for Children More than Two Years of AgeIX. Discussing Developmental Retardation with ParentsX. Summary11. THE PREVENTIVE HISTORY AND WELLNESSI. Importance of the Preventive HistoryII. Preventive History and Preventive Programs for Infants and ChildrenIII. Preventive History and Preventive Programs for Teens and AdultsIV. Preventive History and Preventive Programs for AdultsV. The Positive Promotion of WellnessVI. Summary12. SUCCEEDING WITH THE DIFFICULT HISTORYI. The Good and the Poor HistorianII. Causes for Difficult Histories and their Differential DiagnosisIII. 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 PhysicianVII. Summary13. ENDING THE CLINICAL HISTORY, RECORDING IT, AND INTEGRATING IT WITH THE PHYSICAL EXAMINATIONI. Three Questions to Close the History, Prior to the Physical ExaminationII. Acquiring Additional HistoryIII. Recording the Physical HistoryIV. Integrating the History and Physical Examination to Complete the Initial Medical RecordV. Integrating the History and Physical Examination, Illustrated by Analyzing the Commonest Sympton of All: HeadachesVI. Summary14. THE HISTORY, APPROPRIATE MANAGEMENT, INFORMED CONSENT, AND PATIENT AUTONOMYI. How the Same Techniques for the Clinical History Evaluate Patient Autonomy and Informed ConsentII. Interrelations of Appropriate Management, Informed Consent, and Patient AutonomyIII. Extending the History when the Patient Declines Appropriate ManagementIV. How Promotion of Elective Cosmetic Surgery of Normal Tissues Biases the HistoryV. The Clinical History, Physician-Assisted Suicide, and EuthanasiaVI. The Clinical History, the Living Will, and Planning for Terminal CareVII. An Example of How a Knowing Medical History Guided the Care of a Terminally Ill PatientVIII. Best Examples of the Medical ModelIX. SummaryX. Epilogue: A Personal View15. THE CLINICAL HISTORY OF THE MEDICAL MODEL COMPARED TO ALTERNATIVE MODELSI. THe Science-based Clinical HistoryII. Definition of Alternative MedicineIII. Accomplishments of Physicians who Adhere to the Medical ModelIV. Epilogue16. FOSTERING EMPATHY AND COMPASSIONI. Discovering the Patient's PersonhoodII. Experiences in CompassionIII. Suggestions for Additional SessionsIV. Feeling an Affinity for the Past of our ProfessionV. Selected References for Comparison