Lecture 15 Case Taking: Observation Case taking and Consultation

Question 1

List the 8 elements of Case-Taking

Answer 1

1. Clerical information
2. Reason for visit
3. Red Flags
4. Previous medical history
5. Current treatments
6. Family medical history
7. Lifestyle
8. Anatomical systems check

Question 2

Example Reason for your Visit questions

Answer 2

Open questions:
How can I help you?

So, tell me about your reasons for visiting a herbalist?

How does the pain impact your life?

What you find worsens your bloating?

Closed questions:
Where exactly does it hurt?

When did you receive diagnosis?

How long have you been suffering the symptoms?

What (if anything) makes it better/ worse?

Check if there’s anything else they would like to report.

Question 3

Red Flags

Answer 3

See CNM guide in student portal

Question 4

Example Medical History questions

Answer 4

Any childhood diseases?
Vaccinated?
Ever spend time in hospital?
Ever have the need to take medication?
Pasty surgeries, including dental work?
Any long-term courts drugs- for women include Oral Contraceptive Pill.
What was your health like before they started getting the current symptoms?

Question 5

Example questions regarding Current medically and supplements

Answer 5

Ask about
Doctor prescriptions
Over the counter
Nutritional supplements
Herbal medicines
Homeopathic medicines
Any other treatments, acupuncture, osteopathy?

Question 6

Example questions regarding family health history

Answer 6

Ask about health of parents, siblings, children.
If deceased what age and how did they die?
Ask abut medications taken by family members

Question 7

Lifestyle questions

Answer 7

Ask about
Occupation
Stimulants
Exercise
Pastimes/ recreational activities
Diet
Stress levels

Question 8

Diet questions

Answer 8

Take me through a typical day, B L & D

Sugar, salt, dairy, alcohol, caffeine?

Water intake

What’s on the plate? Including portion size

Question 9

Questions regarding system and organ checks

General

Answer 9

Immunity, infections, wellbeing, energy

Question 10

Questions regarding system and organ checks Cardiovascular System (CVS)

Answer 10

Chest pain, SOB (shortness of breath, palpitations, cold hands/ fee, ankle oedema, varicose veins, orthopnoea

Question 11

Questions regarding system and organ checks

Respiratory/ ENT (Ear Nose and Throat)

Answer 11

SOB, Doug, blood, infections, hard inhale/exhale, wheeze, sputum, smoking

Question 12

Questions regarding system and organ checks Digestion

Answer 12

Appetite, dental, swallowing, indigestion, reflux, acidity, bloating,gas, nausea/ vomiting, blood, number of motions daily, bowel habit, stool colour/ consistency, blood in stool

Question 13

Questions regarding system and organ checks

Urinary

Answer 13

Frequency, urgency, pain/burning on urination, loin pain, blood, stream, incontinence, colour, quantity

Question 14

Questions regarding system and organ checks Gynae/ Reproduction

Answer 14

Female: menarche, cycle length, regularly, duration, PMT, pain, colour, clots, libido, STDs

Male- dysfunction, pain

Question 15

Questions regarding system and organ checks

Obstetrics

Answer 15

Fertility, pregnancies, miscarriages, terminations, menopause

Question 16

Questions regarding system and organ checks

Nervous/ Emotional/ Sleep

Answer 16

Mood, memory, anxiety, stress, energy, sleep (disturbed, hard going off, early waking, nigh sweats, dreams, urination?

Question 17

Questions regarding system and organ checks

Neurological

Answer 17

Faints, headache, tremor, numbness, visual disturbance, dizzy, hearing loss/ tinnitus, pins and needles

Question 18

Questions regarding system and organ checks

Skin

Answer 18

Acne, rashes, fungal infections, herpes, itching, dry, eczema, psoriasis

Question 19

Questions regarding system and organ checks

Musculoskeletal

Answer 19

Joint or muscle pain, crepitations, stiffness, swelling, back pain