by Judith Lande, Gloria Pizzuto and Alberto Muniagurria
The medical history continues to be valid as the first weapon to be used in the relationship of the doctor with the patient. This method contains 50% of the diagnoses and is of fundamental importance to establish contact with the patient, and also allows to take a global vision of the problems that afflict them.
It is not easy to access information in the medical literature on different options that arise both in the interrogation and in the physical examination. In the questioning of the patient, a series of variables are found that modify or contribute a characteristic of their own to the applied method. Due to these variables, the questioning should be adapted to the characteristics of the patients or to the different special situations. The variables to take into account are the following:
The age factor will determine important differences in relation to physiological and anatomical facts, specific needs for prevention and health promotion in the different age groups.
From a practical point of view the ages can be divided into:
Prenatal examination: The data to be incorporated are in charge of the doctor who will take care of the newborn in the future and will deal with family history with special emphasis on diseases of close relatives or kills, communicable diseases that may affect the child. It will take care of questioning about the feeding of the child at birth by questioning the mother about his idea about breastfeeding, and the reasons that justify his choice. It will be questioned about the desire for circumcision of the child according to religious, hygienic, etc. and there will be time to talk about prevention, immunizations, etc.
Questioning in the child from 0 to 6 years
This questioning has similarities in its base and order with that of the adult, but the style of the pediatric interview is different. It varies dynamically with different ages, considering that the attitudes and values (empathy, respect) that facilitate the doctor-patient relationship are equally important in pediatrics. During childhood, the child is the goal and focus of the interview, but is not always the participant.
The questioning will be carried out with parents or relatives in charge of the child or when the child is of age to collaborate and can express their complaint. The difficulties may be related to the fact that the parents' information may be accompanied by their own interpretation or the narration of the child may not be data so easy to estimate.
Well child: This is the time to do the questioning if the prenatal history was not taken. It will inquire about the birth (normal delivery, cesarean sections or other maneuvers). Time should be devoted to assessing the normal patterns of the child's psychophysical development, tooth eruption, eating habits, sleeping, crying; previous immunizations and illnesses.
Sick child: The questioning will include the history of the current illness, past illnesses, common medications, and immunizations.
Questioning the child aged 6 to 12
Healthy child: At this age the questioning will focus on their school progress, games, relationships with family and friends, eating habits, sleep, etc.
Sick child: An examination of the current illness will be carried out with the description of the symptoms that at this age can be carried out by the same child, accompanied by observations from the parents, medications and a history of a similar previous illness.
Interrogation of the adolescent
This age has its own characteristics. It is not necessary to stop in defining this time of insecurities, deficiencies, substantial changes, a hunger for knowledge that all together appear in this adult child. The questioning will be carried out very carefully to understand the reason for the visit, taking into account that at this age the adolescent can play an active role in caring for their health or a passive role being brought by their parents. It should be done alone, even if it is a part. This should be treated in a friendly way and the contents to be discussed are diverse: in addition to the reason for consultation, remember the body changes, sports, sexual initiation, language, schooling, dealing with friends and members of the opposite sex, etc.
The older patient
The questioning of the elderly person should be carried out remembering that this can be a healthy, full and disease-free stage of life, therefore the style of the questioning should be adapted to each case. A question that may be logical to one patient may become insulting to another.
Generally, this patient has had interviews with many professionals throughout his life, which can influence the current relationship. It is convenient to investigate symptoms that are sometimes attributed "to age" or that were previously diagnosed by asking specific questions so as not to prolong the interview too long.
The questioning should focus on your current illness and never ask questions about birth and childhood. Especially in the first interview. Ask about the wife, children and grandchildren, also about their functional capacities (exercises, meals, hygiene, sleep, sexual activity, toilet training). Prescription drugs will be discussed, as well as their physical and financial autonomy. Regarding the mental state, the doctor is able in the interview to realize the patient's condition (if he enters alone or accompanied, if he is walking, in a wheelchair or with a cane, if he is driving, if he hears, or sees well ). According to their mental state, the patient will be questioned or help from a family member will be required. Take into account their appearance and behavior, attention, language,
Female sex: The interrogation emphasizes the physiological facts of the female sex such as menarche, pregnancies, abortions, flow, use of contraceptives, prevention and family violence, as well as the most common diseases in this sex (for example, breast cancer , osteoporosis).
Male sex: The questioning refers mainly to sexual initiation, care, prevention, use of condoms, current sexual activity and the most common diseases in men (for example, dysuria).
Doctor's sex: The patient's preferences regarding the doctor's sex and his inclination to choose his doctor according to sex should be questioned. Sometimes this inclination is related to the required specialty (gynecologists, surgeons, proctologists, urologists, etc.). The affectivity and behavior of each one has influence.
Remember that at this moment in the medical school the student body is almost equally of both sexes.
The place of origin creates ethnic differences, diets, cultural patterns, customs, etc., etc. In addition to heterogeneity between people of the same sex, there are ethnic differences that can be genetic or cultural, religious, nutritional, environmental, economic and social characteristics. For example, thalassemia occurs in descendants of people from the Mediterranean basin. Raw fish is eaten in some countries. There are diseases that are endemic, for example, Chagas and hemorrhagic fever. It should be considered that travelers can carry diseases.
Religion is accompanied by cultural guidelines, customs that are very important for the individual, for their affectivity. It also defines their wishes on such fundamental issues as lifestyle and death. The interrogation deals with eating habits, fasting, circumcision and precepts corresponding to each religion.
Talking about beliefs brings the doctor closer to the human being.
Likewise, the religion of the doctor influences the patient. Sometimes it can be a reason for the professional's choice.
This questioning refers to the patient's workplace, asking about the physical environment where he develops it, regarding contact with chemicals, radiation, metals, arsenic, lead, cereal powders, carbon monoxide, in current and previous work with permanence in them, and also to psychological factors (conformity, pleasure, disgust, conflicts, companions, etc.).
Regarding the family, the area of residence (if it is rural or urban), type of housing, cohabitants, as well as their educational level, cultural belief (for example, regarding cancer, whether it is curable or not, potential use alternative medicine etc.), risk factors in relation to the environment, possibility of recreation, health system or social work.
Inpatient or outpatient
The clinical history of the hospitalized patient is oriented to the specific episode that determined the stay in the hospital or sanatorium. It tends to be complete in relation to the patient's health-disease process. Includes notes from nurses, consulting physicians, paramedics, etc. differing from the outpatient history, which generally has different times, since the patient is supposedly followed for long periods.
Except in multipurpose institutions with a central and unique history, only one doctor writes in the outpatient clinic.
In these days, where the market economy prevails in organizations and its influence on medicine is increasing, the pressure through the systems of social work, translates into demands on the doctor to attend many patients, with reduced hours and poorly paid. It is because of this that the time factor in the office takes on a particular importance.
It is considered appropriate to let the patient speak for a limited period, then using directed questions, always considering that not only the medical time is important but also that of the patient. This may be in a hurry for work, study, etc.
This interview varies if it is the first visit or subsequent visits. In this case, the problem list-oriented medical history allows dedicating the first visit to the acute problem and completing the list of problems in subsequent visits.
In general, the practice of interrogation, for the student, begins in the hospital and frequently with patients admitted to the general ward. This patient has the characteristic of having as much time as necessary to answer the questioning, in addition, he can return if any detail was omitted.
When the practical work of Semiology begins, it is common to receive the following concern from students:
- They do not know enough information about the symptoms and their pathophysiology to question them in depth.
- Patients are generally tired of repeated questioning, studies, etc. They are really sick and upset when not angry at the reiteration.
- Some students perceive that by not having any responsibility for the patient they do not develop a complete experience.
All these reflections have their part of truth; it is clear that they cannot question the symptom like an experienced physician for the purpose of making a diagnosis, but they can learn the clinical method. The gain is learning to speak with the patient to obtain information, characterize the symptoms and create a communication climate so important in the construction of the doctor-patient relationship.
It is true that the patient may not be well predisposed for different reasons. It should be explained to him that the student is learning to question and tell him if they can talk with him about the problems that brought him to the hospital or arrange another interview and in this situation the patient generally collaborates.
When it comes to the help that can be offered, sometimes just listening is a way to help and make you feel better.
It should also be considered that the interrogation of the inpatient varies according to whether he is in a general ward or in a critical area of intensive care.
Interrogation according to who carries it out
Paramedical personnel: It is common in some institutions that, prior to the interview with the doctor, paramedical personnel such as nurses collect general data. This is also common in emergency systems. For these situations it is useful to have printed sheets.
Assistant physician: In medical activity, this model of collaboration occurs frequently. It is carried out by an assistant to the general practitioner who conducts the questioning prior to the interview with him (residents, doctors in training).
Enrolled questionnaires: They must generally be answered yes or no. It is answered by the patient prior to the consultation. Its advantages are that the patient has enough time to think about the answers and it saves the doctor's time. It is most useful for family history information, epidemiology, and problem-oriented medical history.
Its disadvantages are that there may be questions misunderstood by the patient and mainly that it is not a "face to face" interrogation.
Computers: They can be used by groups of doctors for teaching purposes. Generally their use is for questioning and they can be well received by patients alone or assisted by secretaries that allow the doctor to focus her questioning on a selected area and collect very complete information in a short time.
Computers can be used for medical education through interactive sessions.
There are currently programs that allow the registration of the information obtained from the patient during the examination. Technical advancements prevent data from being modified or altered in the future. This is important from a legal point of view.
Interrogation according to your objectives
These may have an educational purpose. It is customary to make the presentation of the clinical history to the instructors or heads of residents and in this case the language should be as precise as possible and the evolution of the patient daily and complete, showing why they should continue to be hospitalized; On the other hand, it is customary to evaluate students by presenting their medical history.
It is important to recognize the great legal medical value in malpractice lawsuits.
It is also used for epidemiological studies, research and by auditors of social works, to evaluate the activity of the doctor and the quality of practice.
Problems that can modify the questioning
During the interrogation, other variables may arise that are related to situations that the interview can modify. These situations can be caused by an illness of the patient, giving as an example when he has some alteration of consciousness (coma, delirium) or due to lack of understanding of the doctor's language (foreigners).
The patient's style or personality has a great influence on the questioning. This can be reticent, broad, somatic, self-sufficient, dramatic, long-suffering, etc.
The "topic" to be dealt with in the consultation frequently generates variables when these refer to taboo topics for the patient, for example related to their sexual activity or habits such as alcoholism or drug addiction that sometimes cannot be treated in the first consultation. The feelings of the individual in the interview should be considered, such as anxiety, depression, anger, manipulation, as well as the feelings that the doctor may express, such as anxiety, fatigue, anger, disagreement, which are reflected in the interview.
Although this chapter is the spring of psychoanalysis, the doctor must know it.
Transfer: process according to which unconscious desires are channeled onto certain objects by a certain type of relationship established with them and in a special way within the psychoanalytic relationship. It is a repetition of children's prototypes lived with a marked feeling of modernity.
Countertransference: set of unconscious reactions of the analyst to the person of the analysand, especially to the transference of the latter; In the doctor-patient relationship, there are different reactions that the doctor may present due to the transference made by the different patients. This is more evident in the family doctor with whom the relationship is more prolonged and sustained.
Questioning according to specificity and sensitivity
The sensitivity or specificity of the symptoms and signs, that is, their predictive value, are of great interest in the questioning. This information should be used in the time devoted to those problems that are more characteristic. For example, fever in lung disease is highly sensitive but not specific since many diseases present with fever. Gastroduodenal pain at night hours after dinner may have specificity, but not great sensitivity since many ulcers do not present it.