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Taengoo

How to approach patients who say YES to every question you ask

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How do you deal with patients, who answer yes, to most questions on your HPI & Review of Systems?

I find these patients tend to embellish their symptoms (i.e chest pain) - perhaps out of mistaken belief that they will be cared for better if they say yes to more questions. Is there something I can do to improve my history-taking skills?

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You look for what's really bothering them and also ask them to rank what's worse/better and also use the pain scale. Then use your physical exam to gauge through it. Dont' forget the psych hx. 

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I mean a lot of the time you do have to give the benefit of the doubt to the patient.

But if someone is coming in with on/off night sweats for 2 weeks with no fever, or weight loss - does it hurt to get a chest X-ray and some blood work? Or if they've had on/off headaches for the past month that has only short term relieve with Advil - does it hurt to get a brain imaging/refer to a neurologist? 

Sure, 90% of the time maybe it will come back normal but that can still put them at ease, but I would think it's worth it for those 10% who it leads to something

Also, a physical exam isn't perfect, I'd use it to complement your findings but wouldn't dismiss anything if the physical exam was normal

I'd love to hear other people's thoughts if you agree or disagree! Every family doc is different :)

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chest pain can be from a lot of things.. if your patient comes to you in your office, you need to do an eval. You don't just indiscriminately send all CP to ER. It could be musculoskeletal, 2e chronic coughing, etc

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I don't agree that more tests/interventions = better care
You need to use clinical judgement. Indiscriminate brain imaging causes unnecessary irradiation. Tests can lead to false-positives (esp when pre-test probability is low, PPV) which lead to more invasive testing. History and physical are important parts of the evaluation to orient your investigations. 

I agree with the above. Use more open-ended questions instead of asking yes-no questions.

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49 minutes ago, F508 said:

I don't agree that more tests/interventions = better care
You need to use clinical judgement. Indiscriminate brain imaging causes unnecessary irradiation. Tests can lead to false-positives (esp when pre-test probability is low, PPV) which lead to more invasive testing. History and physical are important parts of the evaluation to orient your investigations. 

I agree with the above. Use more open-ended questions instead of asking yes-no questions.

Not saying it'd be an automatic go to ER, but even if in my assessment, the patient doesn't have cardiac symptoms, they could still possibly be having or about to have a heart attack, and most FPs don't have access to ECGs or other diagnostic equipment. 85% of chest pain cases in the ER are not threatening, but they are still better equipped to investigate further with the technology they have.  

And re: headaches - I agree that maybe a scan isn't appropriate but a referral to a neurologist is warranted after an adequate history of symptoms and methods attempted. 

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This is a common thing in FP.  The best way to avoid this is to start with open-ended questions to get their story. Use focused "ROS" questions at the end.

This is where FIFEing is actually really helpful in practice.

"what were you looking to get out of this visit?"

"what do you think all of this could mean?"

At the end of the day, you do have to give them the benefit of the doubt. I'll even throw out stuff like "hmm a measured and documented fever for 2 weeks in your baby is usually worrisome that requires a visit to the hospital for investigations.... did they really have a temperature for the entire 2 weeks or did it break during that time". Sometimes they correct themselves, other times they don't.

Most patients are wussies; even with forceful and purposeful questions they'll still skirt around the issue and not ask for what they really want.

 

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On 7/7/2018 at 4:38 PM, brady23 said:

Not saying it'd be an automatic go to ER, but even if in my assessment, the patient doesn't have cardiac symptoms, they could still possibly be having or about to have a heart attack, and most FPs don't have access to ECGs or other diagnostic equipment. 85% of chest pain cases in the ER are not threatening, but they are still better equipped to investigate further with the technology they have.  

And re: headaches - I agree that maybe a scan isn't appropriate but a referral to a neurologist is warranted after an adequate history of symptoms and methods attempted. 

Some clinics have portable ECGs. A patient could be having a heart attack in the absence of traditional MI symptoms, sure, but your training should be preparing you to properly evaluate and refer, not evaluate and then refer anyway because you're thinking of the worst case scenario. 85% of chest pain causes in the ER not being threatening is exactly why ERs are swamped. The FP should be able to reasonably differentiate between cardiac and non-cardiac chest pain.

Referral to a neurologist can take months. On/off headaches in the absence of any other findings again need proper evaluation. A family doctor should be well equipped to deal with headaches. If red flags are present, then of course more urgent referral and imaging is needed.

If you refer everyone out or order every single test to rule out every potential diagnosis you are not doing yourself, the patient, or the system any favours. This is where your differential diagnosis and pre-test probabilities come into play.

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On 7/7/2018 at 1:23 PM, brady23 said:

Also, a physical exam isn't perfect, I'd use it to complement your findings but wouldn't dismiss anything if the physical exam was normal

 

Labs and imaging should complement your physical exam and history, not the other way around.

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On 7/7/2018 at 7:38 PM, brady23 said:

Not saying it'd be an automatic go to ER, but even if in my assessment, the patient doesn't have cardiac symptoms, they could still possibly be having or about to have a heart attack, and most FPs don't have access to ECGs or other diagnostic equipment. 85% of chest pain cases in the ER are not threatening, but they are still better equipped to investigate further with the technology they have.

The whole purpose of the history and physical is to determine whether or not you need to 1) investigate, 2) treat, 3) refer (either to ED or to a specialist) or 4) reassure and watchfully wait. There are many times where you can identify the cause of something based solely on history and physical. Is there a chance you may miss something, just with those alone? Of course there is. But there is also a chance that you will miss something with a diagnostic test, or equally as bad, pick up something thats not there leading to more invasive testing. Medicine is a balance of probabilities and most of the time we are making decisions based on the balance of benefit and harm. If you have a history that clearly indicates that chest pain is benign (no red flags present in a young healthy patient), then it does not make sense to send them to the ED for further workup, but rather watch and follow-up. You need to balance and appropriately use resources as well as manage patients.

On 7/7/2018 at 7:38 PM, brady23 said:

And re: headaches - I agree that maybe a scan isn't appropriate but a referral to a neurologist is warranted after an adequate history of symptoms and methods attempted. 

Again, not every headache requires referral to a neurologist. But of course, some do. There is a very specific list of red flags for headaches that may suggest a more serious cause, but most headaches can be classified based on history alone by any good doctor. Neurologists will get pissed at you if you waste their time by sending them tension and migraine headaches every day (since you will see this daily as a family doctor). Again, it is important to be able to recognize and triage patients based on your history and physical, without relying on testing and specialists. And as always, there is a chance you will miss something, but thats why its important to follow-up with patients and follow their symptom progression until a time where referral may be warranted.

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With these patients, after just a few questions, if I have that kind of feeling, I add a lot of contrary questions or mesically not sound questions to confuse them if I felt like they were trying to embellish or lie. That way, you'll see right away they all of a sudden slow down and think before answering you, they are more likely to be actively trying to fake symptoms/lie/embellish.

E.g.

Headache

- was it so bad you lost consciousness?

- oh did you have a LoC for more than a minute?

- did you also lose memory for a few minutes after the headache?

- did your headache make you feel very short of breath all of a sudden?

I find that mixing real ones with these kind of random odd ones helped me differentiating the truthful patients from the liars in these situations.

Don't get me wrong, I still give them the benefit of the doubt and do my workup properly. 

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In what setting are you asking these questions?

Try to focus your history-taking. If it is really relevant to their presentation, then try to expand on it.

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