236 2021 u3 history taking LIS

UNIT – LISTENING & SPEAKING (2 hours) ENGLISH IN MEDICINE – GENERAL PRACTITIONER Y2 HISTORY TAKING Editor: Nguyen Hoang Quynh Mai Email: 1004quynhmai@gmail.com PRONUNCIATION EXERCISES LISTENING EXERCISES SPEAKING ACTIVITIES PRONUNCIATION EXERCISES Abd pain Abnormal menses Constipation Diarrhea Backache Fecal incontinence Melena Chest pain Headache Visual changes Fatigue Dysphagia Cough Genital complaints Fever Night sweat Indigestion Shortness of breath Hallucination Hematemesis Palpitations Mood disorder Joint swelling Hemoptysis Weakness Nausea/vomiting Mass/lump Joint pain PRONUNCIATION EXERCISES A medical history is a report that includes information gained from a patient's medically relevant recollections (e.g., symptoms, concerns, past diseases) and questioning regarding their concerns While a physician should generally take their time to take a thorough history, situations such as medical emergencies may only provide enough time for a short history to avoid delaying potentially vital interventions Because it takes some practice to distinguish between important and irrelevant information, it is best to follow a set protocol in the beginning 1 PRONUNCIATION EXERCISES Medical history provides the basis on which diagnosis and treatment are developed An uninterrupted setting in a quiet room with only the examiner and the patient present ensures that patients can openly discuss their concerns and reinforces the patient-physician relationship Depending on the patient's concerns, additional and/or more targeted questions may be appropriate Medical histories vary in their depth and focus For example, an ambulance paramedic would typically limit their history to important details, such as name, history of presenting complaint, allergies, etc In contrast, a psychiatric history is frequently lengthy and in depth, as many details about the patient's life are relevant to formulating a management plan for a psychiatric illness 1 PRONUNCIATION EXERCISES The information obtained in this way, together with the physical examination, enables the physician and other health professionals to form a diagnosis and treatment plan If a diagnosis cannot be made, a provisional diagnosis may be formulated, and other possibilities (the differential diagnoses) may be added, listed in order of likelihood by convention The treatment plan may then include further investigations to clarify the diagnosis 2 LISTENING PRACTICE VIDEO: Taking history https://www.youtube.com/watch?v=D8ixnaY5XuQ&t=2638s Listen to this video twice, and fill in the blanks LISTENING PRACTICE 1 Good morning Mr Hall What’s _? They started about ago They’re usually I notice them when I wake up If I _, they seem to go away Has there been from these headaches? LISTENING PRACTICE I’ve had a letter from your doctor and she tells me that you’ve been having And can you remember when it ? In which part of your chest the pain? I had to for it to go away I’ll just _ first of all Fine That’s fine It’s Well now, I want you to in and out while I check your lungs 2 LISTENING PRACTICE Is the temperature there all the time or does it _? And how have you been _? Have you noticed any ? Describe the phlegm: _ I have pains in my chest only if SPEAKING ACTIVITIES DESCRIBE THE PICTURE SPEAKING ACTIVITIES DESCRIBE THE PICTURE SPEAKING ACTIVITIES Opening the conversation: intro., confirm pt., gain consent Presenting complaint History of presenting complaint: SOCRATES & ICE Past medical history Drug history & allergies Family history Social history: bad habits, diet, exercise, occupation Systemic screen Closing the conversation: thanks, summaries SPEAKING ACTIVITIES PMH Have you ever been to the hospital? Have you undergone any surgery? Do you have any other medical conditions? Drug Hx Are you using any medication? Do you have any (documented) allergies? Family Hx Are your parents still in good health? Is there anyone in your family have any long-term health problems? SPEAKING ACTIVITIES Social Hx How many cigarettes you smoke a day? How many years have you smoked for? What kind of food you usually eat? Systemic screen Do you have chest pain/dyspnea/indigestion etc? Do you notice any skin rashes/ulcers/lesions? SPEAKING ACTIVITIES CONVERSATION WITH A PATIENT Introduce yourself - name & role Confirm patient details - name & DoB Explain the need to take history Gain consent Present complaint Ask for details Other symptoms Previous health Summary & next step SPEAKING ACTIVITIES CONVERSATION WITH A PATIENT Work in pairs to make your own story, start with a common symptom that you’ve learned QUESTIONS & ANSWERS ... pt., gain consent Presenting complaint History of presenting complaint: SOCRATES & ICE Past medical history Drug history & allergies Family history Social history: bad habits, diet, exercise, occupation... may be added, listed in order of likelihood by convention The treatment plan may then include further investigations to clarify the diagnosis 2 LISTENING PRACTICE VIDEO: Taking history https://www.youtube.com/watch?v=D8ixnaY5XuQ&t=2638s... paramedic would typically limit their history to important details, such as name, history of presenting complaint, allergies, etc In contrast, a psychiatric history is frequently lengthy and in