236 2021 u3 history taking VOC

UNIT – VOCABULARY & READING (2 hours) ENGLISH IN MEDICINE – GENERAL PRACTITIONER Y2 HISTORY TAKING Editor: Nguyen Hoang Quynh Mai Email: 1004quynhmai@gmail.com ASKING BASIC QUESTIONS 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 ASKING BASIC QUESTIONS 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 1 ASKING BASIC QUESTIONS Starting the interview Ask about duration       Ask about the chief complaint Ask about location What _ the problem? What you here? How long ? When did ? Where ? Can you tell me _? ASKING ABOUT SYMPTOMS  Type & severity  Relieving & aggravating factors  Precipitating factors 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 ASKING ABOUT SYMPTOMS GUESSING WHAT SYMPTOM IS IT? HISTORY TAKING OUTLINE VIDEO: https://www.youtube.com/watch?v=9om2tedf9oo What did the doctor ask his patient? (Put items in the right order) A character of the pain G severity of the pain B expectations of the pt H timing of the pain C onset of the pain I concerns of the pt D present complaint J radiation of the pain E site of the pain K gain consent F relieving factors L confirm name & DoB HISTORY TAKING OUTLINE How would you like me to …? Anything we discussed remain confidential within the medical team as well Tell me a bit about what has been going on I see Would you say …? Overall you’ve made the right decision by coming in 3 HISTORY TAKING OUTLINE You’ve mentioned a few things already Let’s start with … Just let me know if you’d like, okay? I really like to hear your perspective Do you have any thoughts on what could be going on? 10 It’s difficult for people to go through It must have been tough on you as well 11 Any other concerns you would say you have? HISTORY TAKING OUTLINE Opening the conversation: intro., confirm pt., gain consent Presenting complaint History of presenting complaint: SOCRATES Past medical history Drug history & allergies Family history Social history: bad habits, diet, exercise, occupation Systemic screen Closing the conversation: thanks, summaries HISTORY TAKING OUTLINE Site: where? Onset: how it started? Character: how it feels like? Radiation: move anywhere else? Associated symptoms Time course: duration & progress Exacerbating/relieving factors: things make it worse/better Severity EXERCISES EXERCISES TAKING HISTORY IS NOT JUST ASKING QUESTIONS! WRITING PRACTICE What is SOCRATES? (3-5 sentences) What are some questions to ask about symptoms that the patient is having? (3-5 sentences) Introduce the role and main steps of history taking (at least paragraphs) REVIEW 10 MCQS ON KAHOOT QUESTIONS & ANSWERS ... you have? HISTORY TAKING OUTLINE Opening the conversation: intro., confirm pt., gain consent Presenting complaint History of presenting complaint: SOCRATES Past medical history Drug history &... Drug history & allergies Family history Social history: bad habits, diet, exercise, occupation Systemic screen Closing the conversation: thanks, summaries HISTORY TAKING OUTLINE Site: where? Onset:... radiation of the pain E site of the pain K gain consent F relieving factors L confirm name & DoB HISTORY TAKING OUTLINE How would you like me to …? Anything we discussed remain confidential within