An essential part of patient care is determining what is wrong with the patient, that is making a diagnosis. Delaying the diagnosis because of communication problems means delaying proper treatment. Poor communication may also result in the wrong diagnosis, so that the patient receives care which is ineffective or even dangerous. Consequently, effective interviewing of the patient, also called history-taking, is an important clinical skill.
When communicating with the patient who does not speak your language well, you must take the time to confirm information. However, you also have to think of the limitations on your time - you have other patients who also need your attention. Additionally, a long and protracted interview is stressful for both you and the patient. Try to be efficient and accurate, but realize that you may need a little more time than with your Japanese patients in order to check your information carefully. You may find that using charts or pictures helps you to gather more accurate information.
When taking a patient's history, you must think carefully about what is "nice to know" as compared to what you "need to know". In the patient interview, we concentrate on what we need to know. What are the essential details that you need to know about a patient's presenting complaint in order to make a diagnosis? You have probably memorized, or will memorize, a list of essential points that you question every patient about. If you haven't done this already, pause now and make your own list of essential questions.
Ninety percent of the time, or more, you can make a diagnosis from the patient history without any additional tests. Of course, tests are important to confirm your diagnosis. However, you should generally be able to get enough information from the patient interview that you can confidently make a working diagnosis of the presenting complaint.
Situation 1: A 12 year old boy with shortness of breath is brought to a clinic by his mother.
Doctor: Alright, John. Please tell me what the problem is.
John: Sometimes I really get out of breath. I can hardly breathe at all.
Doctor: How long have you had this problem?
John: Just this summer. Last year I was fine, I think.
Doctor: Mrs. Smith, has John ever had a problem like this in the past?
Mrs. Smith: Actually when he was four or five years old, he seemed to have a touch of asthma, but it cleared up when he started school. That was in New Zealand.
Doctor: And when did you come to Japan?
Mrs. Smith: About a year and a half ago. But last summer he was fine.
Doctor: John, is there a time of day when your breathing seems worse or better?
John: Probably its worse in the morning, but any time if I run I have trouble breathing.
Doctor: And is there anything that makes it feel better?
John: Well, if I am running, I just stop running.
Doctor: And how long does it take you to feel better if you stop running.
John: Sometimes just a couple of minutes, sometimes longer.
Doctor: Do you think it has gotten worse lately?
John: Well, actually, it has been pretty bad the last couple of weeks.
Doctor: Mrs. Smith, have you given John any medication for this?
Mrs. Smith: No, at first he didn't really complain about it, and then we realized that it might be asthma again.
Doctor: You're right. It looks like asthma, but we should do a few tests.
Patterns:
*Please ...tell me / explain / describe
...what the problem is
...what is wrong / what is bothering you
* How long have you
...had this problem / had these symptoms
*How long has this been bothering you?
* Have you ...ever had a problem like this / had this
...in the past / before
*Is this the first time you have had this problem?
* Is there
...a time of day when your breathing seems worse/better
...anything that makes your get worse/improve
... something that you do that makes you feel ...
* How long does it
...take you to feel better
...take you to recover
...take for the medicine to work
* Do you think / feel
...it has / your symptoms have, you have
* Have you
...given John / taken / received
Situation 2: A man with low back pain is being interviewed by his chiropractor.
Chiropractor: Can you show me where the pain is?
Man: Well it starts here (running hand around buttock) and runs down my leg.
Chiropractor: Does the pain go below the knee?
Man: It's hard to say. My whole leg feels tight.
Chiropractor: Well, where is the worst pain?
Man: My buttocks.
Chiropractor:Is the pain only on the right side?
Man: At first it was, but now the left side is also pretty tight.
Chiropractor: But is it worse on the right than on the left?
Man: Oh, definitely.
Chiropractor: And how bad is the pain, on a scale of 0 to 10?
Man: Maybe 7 or 8 out of 10. Worse if I cough or sneeze.
Chiropractor: How would you describe the pain when you cough or sneeze?
Man: It's a really sharp pain. It shoots right down my leg.
Chiropractor: Are you able to sleep at night?
Man: Not very well. I always have this intense ache around my buttock.
Chiropractor: Is there anything else that the pain prevents you from doing?
Man: Sitting is worse than standing. And this is kind of embarrassing, but it is hard to go to the toilet.
Chiropractor: Actually, what you are describing is quite common.
Patterns:
* Can you
... show me where / tell me where / describe where
... the pain is / it hurts / the problem is
* Does the pain
... go / spread / radiate
* Where ... is the worst pain / is the center of the pain
...does it hurt the most
* Is
... the pain / it
* How
... bad / severe / painful
* How would / could / do you
... describe / rate
* Are you able to / Can you / Do you
... sleep at night
* Is there anything (else)
... that the pain prevents you from doing
... that you can't do because of the pain
... that makes the pain worse/better
* What you are describing is / That is
... quite common / natural / understandable / nothing to worry about
Discussion:
1. In situation 1, the doctor finds that the young boy's condition developed recently, and is getting worse. What does this lead you to think about the prognosis?
2. In situation 1, we find that the young boy has had a similar condition in the past. What questions might you ask about the previous condition?
3. In the first situation, the mother suspected that the child had asthma. Why do you think that she didn't immediately offer her opinion on the cause of the boy's symptoms?
4. In situation 2, how would you measure the patient's pain? Is there a reliable way to measure how severe a patient's pain is?
5. What other questions might you ask about a patient's pain in order to establish a diagnosis?
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