basic concepts of history taking.pptx
TRANSCRIPT
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Basic concepts ofhistory taking
Dr. Made Ratna Saraswati, SpPD
Tuesday, 12 Oct 2010
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References
Bickley LS, Szilagyi PG, 2009.
Bates Guide to Physical Examination and History
Taking, 10thedition.
Lippincot William and Wilkins, Philadelphia.
Lloyd M & Bor R, 2004.
Communication Skills for Medicine. Churcill
Livingstone, New York
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Patient - Doctor
A patient brings to doctor theirproblems, usually in the form of
symptoms or complain
The doctors role is to gain asaccurate as possible, a picture of the
patients problem
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Developing a management plan for a
patient
Lloyd M & Bor R, 2004. Communication Skills for Medicine. Churcill Livingstone,
Establish
a relationship
with a patient
Gather information:
History
Physical examination
Investigation
Make a diagnosis if
possible
Formulate a management
plan
Explain and
discuss this with
the patient
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Rene Laennec
(French physician)
Listen to the patient.
They are giving you thediagnosis
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Diagnosis changed after investigation
Diagnosis changed after physicalexamination
Fig. Relative contribution of history, physical
examination, and investigations to final diagnosis
83%
8%
9%
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Determining the scope of
your assessment
How much should I do?
Should my assessment be
comprehensive or focused?
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Comprehensive assessment Focused assessment
Bickley LS, Szilagyi PG, 2009. Bates Guide to Physical Examination and History Taking, 10 thedition. Lippincot William andWilkins, Philadelphia.
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Comprehensive assessment Focused assessment
Is appropriate for a new patient in the office
of hospital
Provides fundamental and personalized
knowledge about the patient
Strengthens the clinician-patient
relationship
Helps identify or rule out physical causes
related to patient concerns
Provides baselines for future assessment
Creates platform for health promotionthrough education and counseling
Develops proficiency in the essential skills
of physical examination
Bickley LS, Szilagyi PG, 2009. Bates Guide to Physical Examination and History Taking, 10 thedition. Lippincot William andWilkins, Philadelphia.
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Comprehensive assessment Focused assessment
Is appropriate for a new patient in the office
of hospital
Provides fundamental and personalized
knowledge about the patient
Strengthens the clinician-patient
relationship
Helps identify or rule out physical causes
related to patient concerns
Provides baselines for future assessment
Creates platform for health promotionthrough education and counseling
Develops proficiency in the essential skills
of physical examination
Is appropriate for established
patients, especially during
routine or urgent care visits
Addresses focused concerns
or symptoms
Assesses symptoms
restricted to a specific bodysystem
Applies examination
methods relevant to
assessing the concern of
problem as precisely andcarefully as possible
Bickley LS, Szilagyi PG, 2009. Bates Guide to Physical Examination and History Taking, 10 thedition. Lippincot William andWilkins, Philadelphia.
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Differences between subjective and
objective data
Subjective data Objective data
What the patient tells you
The history, from chief
complaint through review ofsystems
What you detect during the
examination
All physical examination finding
Bickley LS, Szilagyi PG, 2009. Bates Guide to Physical Examination and History Taking, 10 thedition. Lippincot William andWilkins, Philadelphia.
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Differences between subjective and
objective data
Subjective data Objective data
What the patient tells you
The history, from chief
complaint through review ofsystems
Example:
Mrs. G is a 54 years old
hairdresser who reportspressure over her left
chest, which goes into her
left neck and arm.
What you detect during the
examination
All physical examination finding
Example:
Mrs. G is an older, overweight
female, who is pleasant andcooperative, height 154cm, weight
62 kg, BMI 26.14, blood pressure
160/80, heart 96 and regular,
respiratory rate 24, temperature
365o
CBickley LS, Szilagyi PG, 2009. Bates Guide to Physical Examination and History Taking, 10 thedition. Lippincot William andWilkins, Philadelphia.
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The seven components of the
Comprehensive Adult Health History
1. Initial information:
identifying data and source of the history
2. Chief complaint (s)
3. Present illness
4. Past history
5. Family history
6. Personal and social history
7. Review of the systems
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1. Initial information
Date and time of history:the date is always important, be sure todocument the time you evaluate the patientespecially in urgent, emergent, or hospital setting
Identifying data:
age, gender, occupation, marital status
Source of history:
usually the patient, but can be a family memberor friend, letter of referral, or the medical record
If appropriate, establish source of referralbecause a written report may be needed.
Reliability:
Varies according to the patients memory, trust,and mood
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2. Chief complaint (s)
The one or more symptoms or
concerns causing the patient to seek
care Quote the patients own words
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3. Present illness
Each principal symptom should be wellcharacterized with seven attributes
1. Location
2. Quality3. Quantity or severity
4. Timing, including onset, duration, andfrequency
5. The setting in which it occurs6. Factors that have aggravated or relieved the
symptom
7. Associated manifestation
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May include
(which are frequently pertinent to the
present illness):
Medications
Allergies
Habits of smoking
Alcohol and drug
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4. Past history
List childhood illnesses
List adult illnesses
1. Medical
2. Surgical
3. Obstetric/gynecologic
4. Psychiatric
Includes health maintenance
practices
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5. Family history
Outlines or diagrams age and health,or age and cause of death, of siblings,
parents, and grandparents, children
and grandchildren. Specific illnesses in family
History of cancer
Genetically transmitted disease
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6. Personal and social history
Captured the patient personality, interest, sources of support,coping style, strength, and fears.
Occupation
Last year of schooling/education
Home situation and significant others
Source of stress
Important life experiences
Leisure activities
Religious affiliation and spiritual beliefs
Activities of daily living (ADL)
Lifestyle habits that promote health of create risk
Describes educational level, family of origin, current
household, personal interest, and lifestyle
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7. Review of the systems
Documents presence or absence ofcommon symptoms related to each
major body system
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Writing up the patients notes
The notes should be written clearlyand concisely under the same
headings used for taking the patient
history
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Modifying the history taking
sequence
It is important to learn and practice the
history taking sequence. By taking a
history in structure, you are less likelyto miss important information.
However you will need to modify in
some situation.
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Some practical hints
Take every opportunity you are given tointerview
Be prepared to spend time with patient
Skill:
Establish rapport
Listen actively
Ask mainly open question
Pick up and respond to verbal and non-verbal
cues Summarize and check for accuracy
Make an aide memoire sequence
Take note
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