M1: Medical History Flashcards
First step in establishing patient ________ and building a good _______________.
Rapport. Doctor-Patient Relationship.
Can already be made from a good clinical history 80% of the time
Diagnosis
Patients report the story of an illness as they have lived and remembered it. Varies with age, socioeconomic status, culture and experiences.
History
Are a universal human experience, but often have unique personal meaning.
Symptoms
Fact finding & Investigation about the disease. Observation of patient’s behavior and what the illness means to them. A skill and an art.
History taking
Requirements for History taking: Ability to _________.
Listen
Requirements for History taking: Ask ________ questions.
Common sense
Requirements for History taking: Good _________.
Intentions
True statement
Fact
Consists of facts that are arranged in a useful manner
Information
A history is not simply a collection of facts. The facts must be placed in a form that makes them ________.
Informative
Is the explanation the clinician brings to the symptoms. Leads tp the diagnosis and management plan.
Disease
Is how the patient experience the symptoms shaped by previous experiences, how symptoms affect daily living, culture, age and expectations about medical care. _________ must take into account both.
Illness. Health History.
Date and time of examination. Identifying data: name, age, sex, ethnicity, civil status, religion and address. Source of history and reliability. Sources of referral.
General Data
Main reason the patient seeks medical attention. Usually have a single symptom, but may be more. Recorded in patient’s own words. Be careful about recording a diagnosis in this areas.
Chief complaint
Clear, chronological narrative account of present problem. Detailed progression and regression of symptoms very important. Includes prior investigation, confinements and treatments if any. Sequential presentation.
History of Present Illness
HPI: Avoid __________.
Medical terminology
HPI: Must be written or presented in ________ & grammatically correct language.
Concise
HPI: Ability to discern what is ________ & ________ data will come as you learn more about the pathophysiology of the disease.
Essential & Important
Ask about symptoms in the other major body systems NOT mentioned in HPI.
Review of Systems
Review of Systems: Identify ________ the patient has not mentioned so that they are not missed.
Problem
Review of Systems: Identify ________ of other diseases the patient may not know about.
Symptoms
Review of Systems: Identify symptoms which may be _________ for present illness.
Risk factors
If symptoms appear to be related to chief complaint, move ROS to
HPI
Is the key for a good ROS
Systematic Approach
Controversial position in Health History. May be done during Physical Exam. Include pertinent positives and negatives.
Review of Systems
Present known medical problems. Note when diagnosed, meds if any & regular check-up. Current medications with doses, previous illness/confinement/surgery/BT, allergies and immunizations.
Past Medical History
Diseases among first or second degree relatives of the patient, listed according to disease, include age at onset and if cause of death. Review certain conditions (HPN, HD, DM, Ca, Thyroid disease, Seizure & Psychiatric disorders) if considering infectious disease, may require if any family member also have symptoms.
Family History
Includes smoking, alcohol intake, illicit drug use, work/occupation, diet & exercise, water supply & living conditions if necessary, sexual preference & activity and OB-Gyne History.
Personal and Social History
Interview sequence: ________ the patient and _______ rapport.
Greeting. Establishing.
Interview sequence: ________ the patient’s story.
Inviting
Interview sequence: Establishing the ________ for the interview.
Agenda
Interview sequence: ________ and ________ the patient’s story, generating and testing diagnostic hypotheses.
Expanding & Clarifying
Interview sequence: Creating a shared _______ of the problem.
Understanding
Interview sequence: _________ a plan.
Negotiating
Interview sequence: Planning for ________ and ________ the interview.
Follow-up & closing
Interview Strength: Used _______ and allowed patient to _______.
Open ended. Talk.
Interview Strength: Used ________, ________ and ________.
Facilitation, Clarification/Repetition and Summary
Interview Strength: _________ led patient to remember certain symptoms or health history.
Pertinent questions
Interview Strength: ________ & ________ approach.
Nonjudgmental & Nonthreatening
Interview Strength: Asked for ______ & about patient’s ________.
Questions. Concerns.
Interview Strength: _________ plans. Time for ________.
Well-explained. Patient education.
Interview Strength: Make environment as ________ and _______ of distractions as possible.
Private & Free
Interview Strength: Never make ________.
Assumptions
Interview Strength: ________! Follow leads given by the patient asking more _______.
Listen. Direct question.
Interview Strength: Be aware of both ________ and ________ cues from patient & relatives. And beware of your _______ as well.
Verbal & Non-verbal. Own.
Interview Strength: Be aware of your _________ and _________ at all times.
Appearance & Professionalism
The more you know, the more _______ your history becomes.
Pertinent
Let urgency of the patient’s condition be your ______.
Guide
Documentation of patient’s medical history and care.
Medical chart/record
For record of patient’s current status, communication with other parties involved in patient’s care, continuity of care, quality assurance, education and research. Always consider patient’s confidentiality.
Medical chart/record
Guide for Ethics and Professionalism
Tavistock Principles
Tavistock Principle: People have a right to health and healthcare
Rights
Tavistock Principle: Care of individual patients is central, but the health population is also our concern
Balance
Tavistock Principle: In addition to treating illness, we have an obligation to ease suffering, minimize disability, prevent disease and promote health.
Comprehensiveness
Tavistock Principle: Health care succeeds only if we cooperate with those we serve, each other, and those in other sectors.
Cooperation
Tavistock Principle: Improving health care is a serious and continuing responsibility
Improvement
Tavistock Principle: Do no harm
Safety
Tavistock Principle: Being open, honest and trustworthy is vital in health care
Openness
