Taking the Clinical History

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