history taking 1 Flashcards
what is content
info that you need form the pt - info being saught and delivered - discussion of treatment options - management plans the substantive character of the questions and responses
what is process
effective patient centred information
the skills and techniques used to shape the process of the interview eg choice of question style
what should the content of a medical history include
presenting complaint - PC history of presenting complaint - HPC past medical history -PMH social history family history lifestyle functional enquiries/systems review
what is the risk of following a checklist when taking a history
that it becomes Dr centred interrogation so important info might be missed
what should be the beginning of a medical interview
the patients experience of the illness
- convey a powerful message to the pt that you care
- establish supportive relationship and get more info
after this you can integrate closed qns to fulfil the dr centred questions - this is integrated medical interviewing
what is the key to ensure effective integration of content and process
pay close attention to the sequential organisation of the interaction
always need to read the pt because they might give closed answers to open qn so you know how you need to ask qns in order to get the response you need
describe the use of language in medical history taking
need to clarify what pts mean when they use certain terms
pts are becoming more health literate and assertive with their concerns
how do you establish the PC
difficult because pts can be broad/vague or focus on particular symptoms too specifically
need to focus on info given about episodes that caused a change in their health status
why do you need a good intro
provides a stringer entry point into establishing the problem and the pts view of the problem
describe a good intro
full name state role get pts name seek permission state purpose and time frame
how can you meet the patients and interviewers agendas in consultations
clearly state intentions
identify the ots PC and worries/concerns at the start of interview
work with the pt to prioritise these symptoms, worries/concerns
check you understand what the pt is saying
summarise
invite pt to ask qns or clarify anything
consider strategies to help pts express their emotions and then deal with the response
what acronym do you use to discuss pain
SOCRATES
S - site
O - onset (when, suddenly/gradually)
C - character (sharp/knife like/gripping/vice like/burning/crushing)
R - radiation - does the pain spread anywhere
A - association - accompanied by any other features
T - timing - does the pain vary in intensity through the day
E - exacerbating/relieving factors - anything make it better or worse
S - severity - does it interfere with daily activities or sleep
what would ask about in a systems review for cardioresp symptoms
chest pain exertional dyspnoea (quantify exercise tolerance, ie how many stairs) paroxysmal nocturnal dyspnoea orthopnoea (breathlessness when lying flat - a symptom of L ventricular failure) oedema palpitations cough sputum haemoptysis - coughing up blood wheeze
technique for reflection and feedback
the interviewer self reflects and receives feedback from both an observer and the pt
what do you need to ask all patients
name DOB PC PMH ICE social history FH history of presenting complaint medication allergies system review
