EM History Taking

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docB

docB

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GeneralVeers and others made some good points about EM history taking on another thread. I wanted to throw out some tips and see if I could pick up some tricks other docs use to get the story without wasting time. I agree with the open ended opener followed by quick redirect. I open with "Hi. I'm DocB. What's happening today?" as my default.

GeneralVeers said:
I ask one open-ended question: "Why did you come to the ED today?"

I then give them 20-30 seconds to answer. If at the end of that time i have garnered little useful information, I switch to yes/no questions based on what's on the nursing triage note. As long as you're polite about it, the patients usually don't mind.

It's kind of interesting watching our interns have to re-learn how to do H&Ps. When they start off with these talkative patients, they spend 45 minutes in the room listening to the blither. I usually give them 20 minutes before I go rescue them.
Click to expand...

So here are some tips:

-Don't ask open ended questions of car accident victims. When you ask "What happened?" they hear "Give me a detailed account of why the accident was the other guy's fault." For MVAs I ask "What hurts?" and follow up with all the other "Did you get knocked unconscious? Did you have numbness or tingling in your arms or legs?" and so on.

-It's the ED, think dispo. If you've got a guy who needs to go to the cath lab for a STEMI the only thing I care about is who his cardiologist is or if I need to call the on call. Make the page and then dot the is and cross the ts.

-If it's a stroke my fist question is how long it's been going on. If you're a student/resident presenting the case to me it should go "This is an XXyo M with CVA symptoms for X hours." If it's less than 3 get me now. If it's more than 3 continue as you were.

-For the people with chronic and/or multiple complaints the old "What made you come to the Emergency Department today?" can help.

-Another helper for the chronic/multiple complaint crowd is "What can I do for you in the Emergency Department today?" Emphasize Emergency Department. Sometimes you’ll find out that there’s nothing new going on but the PMD told the patient to come get the CT that their insurance company wouldn’t approve.
 
docB said:
So here are some tips:

-Don't ask open ended questions of car accident victims. When you ask "What happened?" they hear "Give me a detailed account of why the accident was the other guy's fault." For MVAs I ask "What hurts?" and follow up with all the other "Did you get knocked unconscious? Did you have numbness or tingling in your arms or legs?" and so on.
Click to expand...

What I say is "I'm not a police officer and I don't wear a badge. I just need to know who hit who how." I will ask what year the vehicle was and what kind (airbag or not, and was it a rollerskate into a dump truck sort of thing), and go from there quickly.

Of course, no one can estimate their speed. At all.
 
Apollyon said:
Of course, no one can estimate their speed. At all.
Click to expand...

My favorite is when EMS tells me the car was absolutely totaled & the driver swears up & down he wasn't doing more than 10mph in that school zone...
 
If I start getting the seeker vibe I'll ask "What medication works for your pain?" I hate getting the chart back 30 min later with "He likes Dilaudid or Percocet better than morphine or Lortab." That's just a bigger waste of time than feeding the seeker in the first place.
 
docB said:
If I start getting the seeker vibe I'll ask "What medication works for your pain?" I hate getting the chart back 30 min later with "He likes Dilaudid or Percocet better than morphine or Lortab." That's just a bigger waste of time than feeding the seeker in the first place.
Click to expand...

I always ask very early in the history "So what medications have you run out of" I'm constantly amazed at the number of problems; pain, sob, nausea, whatever that can be attributed to having run out of something yesterday or this morning.
 
It's only for a select group of patients, but "What non-narcotic pain medication would you like?" is popular in our shop.
 
For social history, the questions, "How many cigarettes do you smoke per day?" ...pause..., "How many days per week do you drink alcohol?", ...pause...and "when was the last time you used cocaine?" get more honest answers than ,"Do you smoke, drink, or use any other drugs?"

Also, for sexual history, asking the question "Do you have sex with men, women, or both?" give people a chance to give a quick one word response feeling less embarrased.
 
I'll typically ask, "Do you have any specialists?" You'd be surprised how many specialists some people have despite having "no medical problems". It usually also gives me an idea as to how to guide some work-ups.
 
"When was the last time you saw any doctor besides an ER doctor"

"When was the last time you felt "like your normal self?" (This is those patients with very vague complaints over very vague time periods)

Instead of "do you have any vaginal discharge" which is embaassing for the patient to answer, I phrase it: "Do you have any vaginal discharge that is more than normal." My attending in residency used to make them show him their panties to prove it, if he thought they were suspicious for PID or trich. um, YUCK

Good points on "What can I do for you here today in the Emergency Department?" Sometimes you get those patients with just exacerbations that "I just wanted an X ray to check for this, or I just ran out of my percocets, blah."

"With one finger, touch the one spot on your body that hurts the most."

I usually don't ask about photophobia, I usually just test for it. Because a lot of times, headache patients will just say "yes" to anything.

I almost always ask abd pain patients WHAT their last meal was. If they say "I can't eat anything" but they just ate Mickey D's or In'n'Out two hours ago, that's different than someone saying "I tried to eat some toast/oatmeal this morning but I couldn't keep it down." Plus it makes for an interesting read in my charts.

Q
 
For abdominal pain patients I do the "cheeseburger test". If it's a big, fat patient with abdominal pain, I'll ask: "If I brought you a big juicy cheeseburger right now, would you eat it?" If they say no, then it's positive for anorexia.
 
this thread came at just the right time. i was told the other day by a senior that i'm prompting +chest pain reports in everyone on ROS.

and today i had a guy who was pan+ on ROS.

how do you avoid the overeager pt who claims to have everything? avoid ROS? or ask as "so you don't have __"
 
GeneralVeers said:
For abdominal pain patients I do the "cheeseburger test". If it's a big, fat patient with abdominal pain, I'll ask: "If I brought you a big juicy cheeseburger right now, would you eat it?" If they say no, then it's positive for anorexia.
Click to expand...

Ah yes, the Cheeseburger Sign. I had a patient back when I was a sub-I w/ acute-on-chronic pancreatitis who would leave her tray of clears untouched every meal for 3 days and was writhing in pain on exam if you looked at her sideways. I walked in semi-announced on day 3 and she was sitting on her bed w/ her husband, eating a cheeseburger and drinking from a pint of cheap vodka. Sorry, no more dilaudid, time to go home.

Unfortunately, this patient and dozens of others like her have made me just assume that anyone presenting w/ abd pain is a liar. But a +ve cheeseburger sign is a dispo plan in and of itself.
 
sese said:
this thread came at just the right time. i was told the other day by a senior that i'm prompting +chest pain reports in everyone on ROS.

and today i had a guy who was pan+ on ROS.

how do you avoid the overeager pt who claims to have everything? avoid ROS? or ask as "so you don't have __"
Click to expand...

ROS is ...BS... there are a few specific questions that *may* link disparate complaints but o/w it is a billing necessity only....
 
I only let them pick 3 + symptoms.
 
We have an awsome EMR and a more-or-less captive population. Frequently, my PMH consists of "are you a Scott & White patient". When they say yes, I'm done and all that is left is cutting and pasting.

My social history of late (assuming it isn't relevant to the complaint) is who do you live with. "Lives with others" box now checked.

For HA, I ask how often they have headaches like this one.

My opening question is "What can I do for you today?".

Take care,
Jeff
 
DrQuinn said:
"When was the last time you saw any doctor besides an ER doctor"

"When was the last time you felt "like your normal self?" (This is those patients with very vague complaints over very vague time periods)

Instead of "do you have any vaginal discharge" which is embaassing for the patient to answer, I phrase it: "Do you have any vaginal discharge that is more than normal." My attending in residency used to make them show him their panties to prove it, if he thought they were suspicious for PID or trich. um, YUCK

Good points on "What can I do for you here today in the Emergency Department?" Sometimes you get those patients with just exacerbations that "I just wanted an X ray to check for this, or I just ran out of my percocets, blah."

"With one finger, touch the one spot on your body that hurts the most."

I usually don't ask about photophobia, I usually just test for it. Because a lot of times, headache patients will just say "yes" to anything.

I almost always ask abd pain patients WHAT their last meal was. If they say "I can't eat anything" but they just ate Mickey D's or In'n'Out two hours ago, that's different than someone saying "I tried to eat some toast/oatmeal this morning but I couldn't keep it down." Plus it makes for an interesting read in my charts.

Q
Click to expand...


I think we as EM doctors are the only specialty that really prides ourselves in writing very legitimate yet very funny and off the wall notes in our charts....but hey, its the truth!

I am young still, but a few I recall:

"....pt stated he checked into the Holiday Inn last PM and masturbated until he was out; he then proceeded to drink rubbing alcohol because he wished to kill himself..."

"PE: General: Patient in no distress, very odiferous" (used that more than once)

"...after PT and I smelled smoke in the room, PT informed me that he placed his lit cigarette into his pocket. Cigarette was exstinguished upon my knowledge of it"

"...PT stated he did have gonorrhea on last visit, but it was scrubbed out by the last doctor that saw him. Informed patient about the importance of antibiotics and that STDs cannot be scrubbed off."

and we have all had this one...

"...PT states he was assulated by two dudes approx 4 hours ago and believes they may have placed an object in his rectum. He denies any further trauma, lacerations, brusing, or swelling"
 
EM_Rebuilder said:
and we have all had this one...

"...PT states he was assulated by two dudes approx 4 hours ago and believes they may have placed an object in his rectum. He denies any further trauma, lacerations, brusing, or swelling"
Click to expand...
I had a patient a while back with the "I woke up and this was up there." story. 4 of Versed later while I'm trying to shove a foley past the object and he's whining I ask him what he was thinking when he shoved this thing up there.
Answer: "I don't know."
 
Jeff698 said:
We have an awsome EMR and a more-or-less captive population. Frequently, my PMH consists of "are you a Scott & White patient". When they say yes, I'm done and all that is left is cutting and pasting.

My social history of late (assuming it isn't relevant to the complaint) is who do you live with. "Lives with others" box now checked.

For HA, I ask how often they have headaches like this one.

My opening question is "What can I do for you today?".

Take care,
Jeff
Click to expand...

This to me seems to be the single most important question in EM. What sucks is when the patient says "figure out what's wrong with me!" This, as you know, usually comes after a rambling history of a "slight" headache, diarrhea x1, a sore wrist, and "I coughed some yesterday."
 
gutonc said:
Ah yes, the Cheeseburger Sign. I had a patient back when I was a sub-I w/ acute-on-chronic pancreatitis who would leave her tray of clears untouched every meal for 3 days and was writhing in pain on exam if you looked at her sideways. I walked in semi-announced on day 3 and she was sitting on her bed w/ her husband, eating a cheeseburger and drinking from a pint of cheap vodka. Sorry, no more dilaudid, time to go home.

Unfortunately, this patient and dozens of others like her have made me just assume that anyone presenting w/ abd pain is a liar. But a +ve cheeseburger sign is a dispo plan in and of itself.
Click to expand...

At one time, I felt the same way - that pts w/abd pain were liars. Then, one day I became ill with a crippling case of diverticulitis and that changed my mind. The attending did a CT and there it was.

I don't eat cheeseburgers or red meat, but I do eat a low fat, high fiber, low cal diet.
 
Antiqueluvr said:
At one time, I felt the same way - that pts w/abd pain were liars. Then, one day I became ill with a crippling case of diverticulitis and that changed my mind. The attending did a CT and there it was.

I don't eat cheeseburgers or red meat, but I do eat a low fat, high fiber, low cal diet.
Click to expand...


I don't think that people with abdominal pain are liars, I just think that a large percentage tend to exaggerate their symptoms. Coupling that with the inability of most patients to provide an accurate history or physical exam, and it could lead to malpractice. That's why I simplify it with the cheeseburger question, and other yes/no questions on the history.
 
I asked a patient today, "So what medical problems do you have?"

He replies, "Hypertension and heart failure."

Later on in the physical exam, I notice he has a fresh scar on his neck.
Me: "What is this scar from?"
Patient: "Oh, I got lymph nodes removed last week. I have Hodgkins Lymphoma."

Apparently "lymphoma" does not qualify as a "medical problem."
Or maybe since it was a new diagnosis he just forgot.
I just chuckled silently to myself 🙂
 
docB said:
I had a patient a while back with the "I woke up and this was up there." story. 4 of Versed later while I'm trying to shove a foley past the object and he's whining I ask him what he was thinking when he shoved this thing up there.
Answer: "I don't know."
Click to expand...

that is awesome!!!
 
For those patients with multiple complaints, I limit them to two or three, and then ask the reverse question: "If you didn't have this belly pain today, would you have come to the ER?" This usually narrows it down to a single reason for me to treat them. OF course, I tell them that I'm going to focus more on whatever they say is most important...
 
No matter how much I try to limit a patient's long winded answers to my yes-no questions, I always seem to get the patient with end-stage fibromyalgia and pan-pain who is a complete life-force-stealing-soul-sucking-dementor-from-hell who can't answer a simple question to save their life.

As a general rule, I get this patient as the first one of the shift after I've been off for awhile.

Apparently, after two or three of these in a row, my ED immune system is back up and running and my patronus is back in prime form.

Take care,
Jeff
 
Jeff698 said:
No matter how much I try to limit a patient's long winded answers to my yes-no questions, I always seem to get the patient with end-stage fibromyalgia and pan-pain who is a complete life-force-stealing-soul-sucking-dementor-from-hell who can't answer a simple question to save their life.

As a general rule, I get this patient as the first one of the shift after I've been off for awhile.

Apparently, after two or three of these in a row, my ED immune system is back up and running and my patronus is back in prime form.

Take care,
Jeff
Click to expand...


Does it look like a squirrel?
 
Jeff698 said:
No matter how much I try to limit a patient's long winded answers to my yes-no questions, I always seem to get the patient with end-stage fibromyalgia and pan-pain who is a complete life-force-stealing-soul-sucking-dementor-from-hell who can't answer a simple question to save their life.

As a general rule, I get this patient as the first one of the shift after I've been off for awhile.

Apparently, after two or three of these in a row, my ED immune system is back up and running and my patronus is back in prime form.

Take care,
Jeff
Click to expand...

OMG, End-stage fibromyalgia.

I just spit up on the screen.

Classic.

-Mike
 
Antiqueluvr said:
At one time, I felt the same way - that pts w/abd pain were liars. Then, one day I became ill with a crippling case of diverticulitis and that changed my mind. The attending did a CT and there it was.
Click to expand...
You're missing the point. The point of the cheeseburger question is to try to determine if the patient is anorexic at that point. Other questions like "Have you been eating? and "Are you hungry now?" tend to get less than optimal responses. Just yeaterday I asked the "Are you hungry?" question which was answered with a firm "No." and then when I left the room the patient demanded to know "When will my lunch tray be here?" so there you go.

In the ED I don't care if someone's lying or not. I usually subscribe to the "You can tell your patient is lying to you when their lips are moving." theory but all get narcs and get CTs if they're actually tender. All I care about is separating surgical from non-surgical causes. Non-sugical can go home. Surgical get a surgeon. EM - It's all about disposition.
Antiqueluvr said:
I don't eat cheeseburgers or red meat, but I do eat a low fat, high fiber, low cal diet.
Click to expand...
Good for you! Is this relavent to this discussion for any reason?
 
PowderHound said:
I asked a patient today, "So what medical problems do you have?"
Click to expand...

clearly the general population doesn't understand this question anymore and we have to invent a new phrase, any ideas?
 
emtcsmith said:
clearly the general population doesn't understand this question anymore and we have to invent a new phrase, any ideas?
Click to expand...

i was taught by a very seasoned IM attending to replace that one question with the following four:
what medicines do you take? (this will often lead to several problems)

what do you see the doctor for? (this will hopefully cover things not covered by meds)

what surgeries have you had? (this hopefully gets the problems that have been cut out, especially CA, CABG, etc)

what are your allergies (why did you take lisinopril that gave you a cough/angioedema, etc?)

obviously you'll ask many/all of these as well, but it can get to the point a bit more quickly, not to mention the frustration involved with negative PMH followed by positive everything else.
 
docB said:
Good for you! Is this relavent to this discussion for any reason?
Click to expand...

:meanie: Although, this is an EM thread. ADD is key here. I'm sure it was linked in their mind....:laugh:
 
southerndoc said:
End-stage? Fibromyalgia is a terminal condition now?
Click to expand...

Absolutely. There is also another form that is hospital acquired: multi-drug resistant fibromyalgia. You know; "Demerol is the only thing that works for my pain!"
 
Seaglass said:
Absolutely. There is also another form that is hospital acquired: multi-drug resistant fibromyalgia. You know; "Demerol is the only thing that works for my pain!"
Click to expand...
Luckily Demerol isn't on the formulary at my hospital. There isn't a single dose of it anywhere in the hospital.
 
Shouldn't end stage fibromyalgia patients be on hospice?
 
For suspicious abd pain, press on belly with scope while listening to bowel sounds. If they don't guard with that, but DO scream in pain when you press with your hand...something is suspicious.

BTW about fibromyalgia...you know, there have been other "invisible" diseases in the past, and pts throughout history have been attacked for being lazy attention/drug seekers, when in fact the medical establishment just hadn't figured out the etiology yet.
 
brianmartin said:
BTW about fibromyalgia...you know, there have been other "invisible" diseases in the past, and pts throughout history have been attacked for being lazy attention/drug seekers, when in fact the medical establishment just hadn't figured out the etiology yet.
Click to expand...

As I told a patient, I don't believe that "fibromyalgia" is an actual thing, and that it is somatic representations of psychological problems. I said that, certainly, you have pain, but we're not looking at it from the right perspective. As I said, "fibromyalgia = chronic fatigue = irritable bowel = interstitial cystitis = depression". Have you seen the Cymbalta commercial? "Depression hurts". There it is.
 
brianmartin said:
For suspicious abd pain, press on belly with scope while listening to bowel sounds. If they don't guard with that, but DO scream in pain when you press with your hand...something is suspicious.
Click to expand...

This has been my trick since I was a 3d year. The thing is, I need to get to it before my resident/intern/student/attending gets there w/ their big grubby paws and starts mashing on the place where they say it hurts.

That and the good old "bed bump" is about all the abd exam you need in most folks.
 
brianmartin said:
For suspicious abd pain, press on belly with scope while listening to bowel sounds. If they don't guard with that, but DO scream in pain when you press with your hand...something is suspicious.

BTW about fibromyalgia...you know, there have been other "invisible" diseases in the past, and pts throughout history have been attacked for being lazy attention/drug seekers, when in fact the medical establishment just hadn't figured out the etiology yet.
Click to expand...
I keep asking questions while palpating the abdomen. If their tenderness and guarding disappear when they're distracted then it's supratentorial. Good questions for this include "Have your toenails been hurting?" (a "yes" = the globally + ROS = bs) or, if you really want them distracted, "What pain medicine works for you?"

Speaking of supratentorial pain, I don't really care if fibromyalgia is real or not, it's not dangerous and doesn't need to be in the ED.
 
edinOH said:
Shouldn't end stage fibromyalgia patients be on hospice?
Click to expand...

Speaking of hospice...

I don't know if y'all have received this memo yet but apparently hospice isn't just for those with DNRs anymore.

I've had several patients recently who come in from hospice care, with hospice paperwork and, in one case, with a hospice nurse who were quite adamant that they were to be fully resuscitated.

Apparently my rather confused expression led the hospice nurse to tell me that, no, in fact, hospice does not equal DNR.

Important safety tip. I obviousy want to honor my patients wishes about this but, seriously, this is a confusing development.

Take care,
Jeff
 
Jeff698 said:
Speaking of hospice...

I don't know if y'all have received this memo yet but apparently hospice isn't just for those with DNRs anymore.

I've had several patients recently who come in from hospice care, with hospice paperwork and, in one case, with a hospice nurse who were quite adamant that they were to be fully resuscitated.

Apparently my rather confused expression led the hospice nurse to tell me that, no, in fact, hospice does not equal DNR.

Important safety tip. I obviousy want to honor my patients wishes about this but, seriously, this is a confusing development.

Take care,
Jeff
Click to expand...

wow...good to know. I just assumed it was for those with DNRs. After all, don't they have to be told they only have a certain amount of time to live before they can even be on hospice, or am I completely wrong about this?
 
"-If it's a stroke my fist question is how long it's been going on. If you're a student/resident presenting the case to me it should go "This is an XXyo M with CVA symptoms for X hours." If it's less than 3 get me now. If it's more than 3 continue as you were."

unless you work in a new and improved interventional stroke center where they do site specific intravascular tpa up to 12 hrs.....

regarding the 1 finger test anyone heard about the blond who hurts everywhere she touches herself and just has a broken finger.....🙂
 
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