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History taking for the practice nurse

Article in Practice Nurse · July 2015

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HOME CLINICAL A-Z CURRICULUM ESSENTIALS PRESCRIBING NURSE ADVANCED PRACTICE GUIDELINES

JULY 2015
Dr Mary Lowth
MA MB BChir FRCGP PGCMedE

History taking for the GP and MRCGP examiner

practice nurse
Taking a history is a crucial part of any consultation, but not all
of us have natural aptitude for the listening and
communication skills that are essential to effective history-
taking

'Listen to your patient, he is telling you the diagnosis.’

These are the words of William Osler, a Canadian physician at the turn of the
last century who has been called the father of modern medicine,1 and they
sum up the art of effective history taking.

Practice nurses are increasingly involved in seeing unselected patients in

primary care. Taking a history is a crucial part of any consultation, both to
allow the nurse to gather the information that makes the encounter medically
useful, but also as a means of opening communication with the patient in
order to make them a partner in their own management.

History taking aims to

Establish rapport
Understand what the patient is experiencing
Compare that against your knowledge and experience
Formulate a likely diagnosis and a differential diagnosis
Understand their ideas, concerns and expectations

It can also help to think of the process as gathering two kinds of data:

A clear picture of the problem from the patient’s point of view

A clear picture of the problem from your medical point of view

WHAT SKILLS ARE NEEDED?

Good history taking needs

Communication skills to build rapport and ensure understanding

Ability to listen and respond
Clinical knowledge including
Knowledge and experience of common conditions and
presentations
Knowledge of and alertness to uncommon but important
conditions
Ability to think logically through clinical algorithms
 In primary care we also need to do this in a time-efficient way.

Perhaps the most crucial skill is the ability to listen to what the patient is
saying.

This sounds simple, but it’s amazing how many people plough through history
taking without really listening to the patient’s answers. This is inefficient, and
can send you in the wrong diagnostic direction. It’s far more effective to
assimilate the replies, as you go on, in order to start to narrow down the
options.

The ability to listen and communicate well is not innate. Some of us are better
at it than others, and we may have to work at it. Good communication begins
with listening and observing, in order to understand how best to pitch our
approach in terms of language, content and manner. Techniques such as
mirroring posture and reflecting back comments may help show patients that
you are focused on them and hearing their responses.

LEARNING TO TAKE A HISTORY: THE BUILDING BLOCKS

When we first learn history taking we use a series of structured questions.

This is sometimes termed the hospital clerking model. (See box)

This approach is thorough, makes us certain we’ve missed nothing and

extracts lots of data from the patient, but it is time consuming because it asks
each patient a very full set of questions. This makes it harder to discard
what’s not relevant as you go along, and it tends to concentrate the mind of
the questioner on their questions, rather than on the answers. At worst it can
mean that the doctor or nurse does all the talking. This may disengage the
patient, who may wonder why they are being asked if they have ever passed
a kidney stone when they are presenting with pneumonia.

Learning this basic method is essential in our training, as it is part of the basis
from which we construct our focused history. Only when we have it committed
to our memory can we then select from it the bits that matter. It also gives us
a thorough set of questions to fall back on if none of our differential diagnoses
seem to fit the symptoms.

ASKING QUESTIONS

Questions should be asked one at a time, and negative questions (e.g. you
don’t get itchy with it, do you?) should be avoided: they are potentially
confusing. They may alarm patients, or patients may agree with them without
listening properly because they want to agree with you.

Reserve personal or intimate questions until rapport is established, and use

appropriate warnings to signal to the patient that they are coming.

There are various types of question:

Open questions

Open questions are those that allow the patient to answer freely. They:

Allow the patient to expand on symptoms

Allow you a fuller understanding of their experience
Mean that patients tend to talk more than the doctor/nurse
Allow the patient to feel heard and to become a partner in their own
consultation
Help develop a patient-centred manner

Some examples of open questions are:

Describe the pain to me?

Tell me a bit more about the rash?
How do you feel about all this?

Open questions are useful early in the consultation when you want to get
maximum information from the patient and encourage them to talk. But they
can use up time if patients are very talkative or raise multiple unrelated
symptoms that confuse the picture

Doctors and nurses often talk about a golden minute (or even a golden two
minutes) at the start of a consultation, when you let the patient explain their
situation and try not to interrupt.
Closed questions

Closed questions are those that have a limited choice of answer. They:

Limit the patient to short answers or even yes/no

Allow you to drill down and get fast answers around symptoms that
worry you (e.g. does the rash blanch when pressed?)
Can be a time-efficient way of finding out specific facts that the patient
may not rank as important enough to mention
May increase the patient’s confidence in the doctor or nurse (as they
demonstrate that you have heard the symptoms and are analysing
them)
Can mean the doctor or nurse is talking more than the patient
Can make the consultation feel doctor/nurse-centred and the patient
feel excluded, if used excessively/inappropriately

Closed questions are generally more useful later in the history taking when
you are seeking to confirm your thoughts on diagnosis or to rule out red flags.
Some examples are:

When exactly did the pain start?

Does the rash blanch when you press it?
What time do you wake in the morning?

Probing questions

Probing questions lie somewhere between open and closed questions. They
may follow up an open question to narrow down the responses, for example

How does the pain affect your ability to manage your day?
How does the bullying make you feel?
What’s your sleep pattern been like this last week?

Probing questions help clarify the open answers and are time-efficient without
shutting down the patient’s share of the discussion.

Open, closed and probing questions all have their uses and all are needed in
good history taking. Generally open questions should predominate at the
beginning of the consultation, when the patient should normally do most of
the talking, and closed questions come to the fore as you begin to formulate
your diagnosis and cross check it.

The proportion of time spent on the different types of question will vary with
the consultation. You may need to move to closed questions very early if the
diagnosis is very obvious, if red flag symptoms are revealed or if the
presenting complaint may be life threatening. In these circumstances
becoming very doctor/nurse-centred is often the most appropriate course.

ORGANISING THE PRIMARY CARE HISTORY

Prepare for the patient, if you have access to their notes. Even in a very
rushed clinic, try to look at the last encounters with the surgery, any recent
hospital letters and the clinical summary. Patients who attend regularly may
be very upset if your initial questions suggest you know nothing about them.

1. The presenting complaint

The first part of the history should always be about establishing why the
patient has come. This helps your thinking, makes sense to patients and
helps them to put their story together clearly for you. Keep your questions
very open. ‘What have you come to see me about?’ ‘Tell me more about that.’

Some people suggest avoiding, ‘What can I do for you today?’ on the basis
that it raises expectations. The author has used this phrase for many years
and has never found it to be a problem, and patients have felt it indicated an
intent to help.

We refer to the reason for attendance as the ‘presenting complaint’ and the
information about this the ‘history of the presenting complaint’:

What is it?
How long has it been a problem for?
Is it getting better, getting worse or staying the same?
What relieves it or makes it worse?
 If it’s pain, what’s it like? Where? When does it come on? Where does it
spread to?
How does it make you feel? How is it affecting you?
What do you think it is? Is anything worrying you about it?

2. Background

Other information may then be helpful, depending on the circumstances.

Working your way through the following areas, leaving out those that you feel
are irrelevant to the problem, can be helpful. Consider:

Past medical history (chronic conditions, conditions requiring

medication and the most recent are usually, but not always the most
relevant). Ask about major or important illnesses or operations
Medication – including over-the-counter and herbal remedies – present
and also past
Family history – who is there, how are they? Any illnesses in the family?
Social history – smoking, alcohol, drugs, life circumstances, who is
there for your patient? Do they work?
Systems review: there are specific questions for the cardiovascular,
respiratory, abdominal, neurological, musculoskeletal and GU systems.
Not all will be relevant or necessary in every consultation
In children – immunisation and developmental history
In women of childbearing age, obstetric and gynaecology history

3. What matters to the patient? Discovering the agenda

Understanding the patient’s perspective is crucial to patient satisfaction. The

Disease-Illness model of consulting may be helpful.2 It looks at your patient
encounter as shows two parallel agendas.

For example, you see a patient with knee pain. Your agenda may be to rule
out ligament injury by arranging imaging. The patient’s agenda may be to
play in the football final on Saturday. Your basic goals are the same, to arrive
at the correct diagnosis and to get the patient better, but the perspectives
differs.

The patient’s agenda involves their ideas, concerns and expectations,

and is set in the context of their life and experience and emotional
milieu.
Your agenda involves wanting to be correct, do the right thing and
achieve the right long-term outcome.

If you don’t make sure you’ve worked out the patient’s agenda they may
leave the consultation with their main question unanswered.

It’s important in history taking to ask, early on, not only what the patient is
experiencing but also what their perspective is. What are they concerned it
might be? What has experience led them to conclude? What do they hope
you can do today?

4. Focused and probing questions

Use the rest of the history to probe around the problem. By now you should
be building a list of differential diagnoses and trying to work out which fits.

Closed questions may be useful. Rule out sinister and life threatening
conditions. If you can’t rule them out then they remain possibilities, and even
if they are less likely than your main diagnosis you must act on them.

5. Examination

This is a part of clinical data gathering and belongs with history taking – but
the art of focusing your examination is important in primary care. This will be
discussed in a future article.

Winding up

Once you have completed your history taking, consider summarising back to
the patient. This can be as helpful to you as to them as it helps you gather
your thoughts. So you might say, ‘so you’ve had the pain since Thursday, it
comes and goes in waves, it’s getting steadily worse and you feel sick with it.
You’ve not had any other symptoms and your bladder and bowels have been
working normally. You think it might be related to the chicken you ate the
night before. Is that all correct?’
By now you should have formulated a list of differential diagnoses, and
hopefully there’s one that you think is more likely. It’s time to move on to
communicating, to the patient, the list of possibilities, the one you think most
likely (and why), and what you suggest they do next.

Summary

History taking is both a science and an art. Good history taking helps
establish a communicating and helpful relationship with the patient, as well as
providing the information we need in order to make a diagnosis, in a time
efficient manner.

Good history taking needs knowledge, skill and experience. The practice
nurse is well placed to become an expert in this area.

REFERENCES

1. The Osler Symposia http://www.oslersymposia.org/about-Sir-William-Osler.

html

2. Stewart M et al. Patient-centred medicine: transforming the clinical method.

Abingdon Oxford; Radcliffe Medical Press; 2003

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