Taking a Medical History
اسلاید 1: www.tabaye.ir
اسلاید 2: Taking a Medical History: A surprisingly complicated procedureSean Reed, M.D.Assistant ProfessorDepartment of Family Medicine
اسلاید 3: Content of Medical HistoryChief ComplaintHistory of Present IllnessPast Medical HistoryFamily HistorySocial History (Patient Profile)Review of Systems
اسلاید 4: Feel like you are getting only half of a very complicated storyMYSTERYYou’re not at all sure where the story is going and you are afraid of wasting timeYou understand what the patient is saying, but you are not sure what is going on
اسلاید 5: Chief Complaint (CC)Patient’s main reason to seek careAgenda settingHidden agendas
اسلاید 6: Chief Complaint:“My wife made the appointment for me”“I can’t find my penis”“Cell phone injury”… Family history of diabetes… Congestive heart failure… Five sutures to the forehead and a tetanus shot
اسلاید 7: “Is there something in particular that you are worried about?”
اسلاید 8: SKILLS DONE WELL OK, COULD BE BETTERNOT DONE OR DONE POORLYNOT APPLICABLE1. Introduces self and explains purpose of interview.321N/A2. Attends to the patient’s comfort and privacy.321N/A3. Allows patient to describe the illness/chief complaint.321N/A4. Uses the following techniques effectively (Note: you don’t have to use them all!) Open-ended questions Reflection/Repetition Clarification Silence Facilitators (nods, uh-huh, etc…) SummationOVERALL USE OF INTERVIEWING TECHNIQUES333333322222221111111N/AN/AN/AN/AN/AN/AN/A5. Balances listening with structure.321N/A6. Follows up on cues and vague statements.321N/A7. Attends to patient’s nonverbal cues.321N/A8. Responds empathetically and supportively.321N/A9. Closes interview appropriately.321N/A
اسلاید 9: Power Tools/Techniques BENEFITS:Body posture and movementsEye contactFacial expressionInflection, tone of voice and rate of speechTouchSpace between doctor and patientFOUCS:FacilitationsOpen-ended questionsClarification and directionUnderstanding by checkingSurveying problemsAVOID:leading questionsmultiple questionsSUMMARIZE:Feedback to patient your understanding of storyIf you are lostIf you are uncertainIf done/transition
اسلاید 10: Getting startedWhat brings you in today?How can I try and help today?What would you like to discuss today?I see that you have told the nurse…
اسلاید 11: History of Present Illness (HPI): Physician-centered framework: 7 Symptom characteristicsLocationQualitySeverityTimingSetting/contextModifying factorsAssociated symptoms
اسلاید 12: Pain History (“OPQRST”): Onset and Occasion when symptom first was noticedProvocative and Palliative factorsQuality and/or Quantity of symptomRegion of body and Radiation to other areasSeverity of symptom (0 to 10 scale, if applicable) and associated SymptomsTime (duration) and Temporal associations (what is going on when symptom occurs)
اسلاید 13:
اسلاید 14: Past Medical HistoryMajor illnessesHospitalizationsSurgeriesSignificant injuriesMedicationsAllergiesImmunizationsTransfusionsGynecologic and obstetric historyPsychiatric history
اسلاید 15: Past Medical HistoryMedical Illnesses – identify chronic illnessesHospitalizations - approximate datesSurgeries - approximate dates/reasons(ex: hysterectomy – benign or malignant?)Significant injuries
اسلاید 16: Past Medical HistoryMedicationsname, dosage, frequency, reasonOTC, herbal, vitamins, supplementsOther alternative medicine therapiesAllergies– describe reactionImmunizations TransfusionsGyn and Ob historyLMP, birth control usePast psychiatric history
اسلاید 17: Family HistoryCurrent health of familySpecific familial diseasesOther family members with similar illnesses
اسلاید 18: “Patients rarely volunteer a family history of mental illness or addiction”
اسلاید 19: Social History / Patient ProfileHow do lifestyle or personality traits:Contribute to causality of illness?Aggravate or limit severity of illnessInterfere or help with getting wellThe “usual day”
اسلاید 20: Social History/Patient ProfileDemographic informationOccupational and educational historyMilitaryTravel historyRefugee historyHealth HabitsSmoking, Alcohol, Drug useExerciseDietSexual historySignificant relationshipsSpiritual, cultural and health beliefs
اسلاید 21: What do you do for a living?What do you do for fun?
اسلاید 22:
اسلاید 23: Review of SystemsUncover other medical problemsIdentify symptoms that may be related to presenting symptomsMove from general to specific questionsPositive responses need further clarification
اسلاید 24: SUMMARYInterviewing gems Is there something in particular that you are worried about?What do you do for a living?What do you do for fun?Don’t forget your power tools / techniques7 Symptom characteristicsLocationSetting/contextQualityModifying factorsSeverityAssociated symptomsTimingSummarize the visitAsk for questionsDescribe next stepinvolve patient, if decision needed
اسلاید 25: Thank you for listening
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