History Taking In Surgery Flashcards
What is a case history
A planned professional conversation that enables the patient to communicate his or her symptoms, feelings and fears so as to obtain an insight into the nature of the patient’s illness and his or her attitudes towards them
What are the objectives of history taking
To establish a positive professional relationship
To provide the clinician with the information that may be necessary for making a diagnosis
Documentation (to pass the information to others)
Individualization (ensuring that care is individualized related to age, social history, etc)
provide information that aids the clinician for making a diagnosis - symptoms and risk factors
To provide information concerning the treatment of the patient - staging, complications, co-morbid conditions
What is the means of getting information from the patient
Allowing patients to tell their own story assisted by open ended, close ended and directed/targeted questions
Which of these is more than 10cm
Lump or mass
Mass
Which of these is less than 10cm
Lump or mass
Lump
Which part of the history should be stated in the patient’s own words
PC