Fundamentals of History Taking Sept5 M1 Flashcards
6 tasks of clinician
Diagnosing, determining cause, prognosticating, treating, maintaining health and preventing disease, healing
3 tools of the clinician
history taking, physical exam, clinical reasoning
Things to do in initiating the session (4)
Greet patient and get name
Introduce self
Appropriate opening question
Listen without interruption
Providing structure steps (5)
why here? who is the person? past medical history? present illness? patient perspective?
Closing interview with patient (3)
SUMMARIZING
ask if other questions
thanking
Components of a medical history (5)
Patient Profile, Reasons for visit, Past Medical History, HPI with patient perspective
Medications, Allergies, PERSONAL history, family history, functional enquiry + smoking and alcohol
What we mean by patient profile
Age, ethnic background, home and family situation, occupation, other events
7 components of the history of present illness
Body location, chronology, quality, quantity, aggravating and alleviating factors, associated manifestations, patient perspective
body location assessment
be specific, have patient show it
chronology assessment
time of onset, duration, frequency, evolution, final event that made you come
quality assessment
use patient’s words, descriptive
prompt with words like squeezing, sharp knife, burning feeling
quantity assessment
assess anything that can be quantified with the symptom
fever: temperature
pain: how much
diarrhea: how many times
what quantity gives us
linked to function. more intense = feels worse
aggravating and alleviating factors assessment
ask about it, suggest: MEDICATION, position, after eating, activity, breathing and coughing
associated manifestations (2 things and one very important)
ask for other symptoms we might see in the system involved
ASK ABOUT GENERAL SYMPTOMS
