History Taking

DrRasool M Hasan

• 1- Identity name age address residency

occupation gendre marital status., religion• 2-Chief complaint: 1-3 + duration• 3- Hx of present illness.• 4- Review of systems.• 5- Past medical hx.• 6- Past surgical Hx.• 7- Family Hx.• 8- Occupational Hx.• 9- Menstrual Hx.• 10- Drug Hx.

Chief complaint• Symptoms:• CVS easy fatiguability, sob,

orthopnea, PND, cough, chest pain, dizziness, cold sweating, leg edema, bluish discoloration, clubbing, abd. Distension, nocturia, syncopal attack, hx of hypertension, hemoptysis,

still symptoms• Respiratory syst. Cough, sputum,

hemoptysis, chest pain,wheeze, easy fatiguability, bluish discoloration, clubbing, painful wrists and feet. Fever, hx of any communicable dis., stridor, aphonia inability to talk. Bovine cough

cont. symptoms• GIT loss of appetite, wt loss, pain inside

the mouth, diffic in swallowing for both fluid and solid, pain with swallowing ,regurgitation of fliuid from the nose, nausea, vomiting, hematemesis,malena, fresh blood per rectum, jaundice, pale stool, abd pain ( epigastric, umblical, suprapubic), pallor, angular stomatitis, beefy tongue.

• THE DUTIES OF A DOCTOR REGISTERED WITH THE UK

GENERAL MEDICAL COUNCIL• Make the care of your patient your first concern • Treat every patient politely and considerately • Respect the patient's dignity and privacy • Listen to patients and respect their views • Give patients information in a way they can understand • Respect the rights of patients to be fully involved in

decisions about their care • Keep your professional knowledge and skills up to date • Recognise the limits of your professional competence • Be honest and trustworthy • Respect and protect confidential information • Make sure that your personal beliefs do not prejudice your

patient's care • Act quickly to protect patients from risk if you have good

reasonto believe that you or a colleague may not be fit to practise

• Avoid abusing your position as a doctor • Work with colleagues in the ways that best serve patients'

interests

• SOME BARRIERS TO GOOD

COMMUNICATION IN HEALTH CAREThe clinician

• Authoritarian or dismissive attitude • Hurried approach • Use of jargon • Unable to speak first language of patient • No experience of patient's cultural

background

• The patient• Anxiety • Reluctance to discuss sensitive or

seemingly trivial issues • Misconceptions • Conflicting sources of information • Cognitive impairment • Hearing/speech/visual impediment

• The main aim of a medical interview is to

establish a factual account of the patient's illness. However, this is not enough; the clinician must also explore the patient's own feelings, determine how they interpret their symptoms, and unearth all their concerns and fears before suggesting and agreeing a plan of management. These goals will not be met unless clinicians demonstrate understanding and empathy (i.e. imagine themselves in the patient's position). Empathy is not the same as sympathy (feeling sorry for the patient), which is rarely helpful. Most patients have more than one concern and will be reluctant to discuss potentially important issues if they feel that the clinician is not interested, or is likely to dismiss their complaints as irrational or trivial.

• Listening and talking to the patient with care

and skill will usually lead to a provisional diagnosis, establish rapport, and determine which investigations are likely to be most productive. The clinician must allow the patient to describe their problems without overbearing questioning, but should try to facilitate the process with appropriate questions . Non-verbal communication is equally important. The patient's facial expressions and body language may betray hidden fears. The clinician can help the patient to talk more freely by smiling or nodding appropriately.

• The doctor must also ensure that

dignity is preserved and that the patient feels comfortable throughout the examination; this may entail the presence of a chaperone and always requires explanation in advance of whatever examination is to be performed

• THE MEDICAL INTERVIEW: QUESTION

TYPES• Open questions allow the patient to

express their own thoughts and feelings, e.g. 'How have you been since we last saw you?', 'Is there anything else that you want to mention?'

• Closed questions are requests for factual information, e.g. 'When did this pain start?'

• Leading questions invite specific responses and suggest options, e.g. 'You'll be glad when this treatment is over, won't you?'

• Reflecting questions help to develop or expand topics, e.g. 'Can you tell me more about your family.

• THE NOVICE-EXPERT SHIFT• Novices use pre-determined methods which they learn • Advanced beginners recognise that these methods

are not effective in all circumstances and can adapt them according to context

• Competent professionals are able to make conscious independent choices and can manage and regulate their own practice

• Proficient professionals make use of intuition based on experience; integrate multiple aspects of practice in a holistic model

• Experts function largely through 'unconscious competence' and are inseparable from the tasks they undertake

PERSONAL AND PROFESSIONAL DEVELOPMENT • Good doctors never stop learning, and

continue to develop their knowledge, skills and attributes throughout their working lives, to the benefit of their patients and themselves. Personal and professional development (PPD) requires a reflective and self-directed approach to the study and practice of medicine , and will maximise both life-long effectiveness and personal satisfaction. Linked to this is the concept of the novice-expert shift

• SOME APPRAISAL TECHNIQUES• Formal, structured assessment (e.g.

postgraduate examinations) • 360-degree assessment (surveying colleagues

from medicine and other disciplines who work alongside the practitioner)

• Educational supervision and mentoring (a specific colleague has nominated responsibility to guide, and also assess, the practitioner)

• Logbooks (records of work undertaken and outcomes)

• Portfolio-based assessment (the practitioner accumulates a record of educational and clinical experiences together with evidence of reflective practice)

• PPD begins in the first days at medical school

and continues through postgraduate training and subsequent professional practice; maintaining competence and expertise requires continuous professional development (CPD). In the UK this is formally regulated by professional bodies such as the Royal Colleges, and is linked to processes of appraisal and re-accreditation for established practitioners. To support this process, outcomes and competences for PPD are being defined at all levels of medical training, including undergraduate and postgraduate study. These sit alongside and complement curricula that focus on discipline-based knowledge and skills.

AUDIT • An important element of reflective

learning is audit of clinical practice against recognised standards, many of which are now published as guidelines.

Guidelines • A large number of local and national bodies

(e.g. in the UK, SIGN-Scottish Intercollegiate Guidelines Network; NICE-National Institute for Clinical Excellence), as well as international ones (e.g. the World Health Organisation), have produced treatment guidelines based on rigorous and systematic reviews of the medical literature. Although these guidelines are authoritative they are only applicable to certain well-defined situations and do not substitute for good clinical judgement.

Recurrent abdominal pain• Is there a family history of

migraine or epilepsy? Migraine and epilepsy both present with abdominal pain.

• Is the pain colicky or persistent?

Chronic colicky abdominal pain may be due to chronic cholecystitis, cholelithiasis, renal calculus, or partial intestinal obstruction.

• What is the location of the pain? If the pain is located in the upper abdomen, then one should consider peptic ulcer disease, pancreatitis, cholecystitis, and cholelithiasis. If the pain is located in the flanks, one should consider renal calculus and pyelonephritis. If the pain is located in the lower abdomen, one should consider diverticulitis, salpingitis, endometritis, and chronic appendicitis. Regional ileitis also may be located in the lower abdomen, particularly in the right lower quadrant.

• What is the relationship to meals?

Abdominal pain relieved by food may be due to a peptic ulcer. Abdominal pain brought on by food may be due to abdominal angina. If the pain comes on 2 to 3 hr after a meal, it may be due to a peptic ulcer. On the other hand, pain that comes on 1 to 2 hr after meals, especially if it's a fatty meal, may be related to cholecystitis and cholelithiasis.

• Is there fever associated with the

abdominal pain? Fever and abdominal pain may be due to pyelonephritis, diverticulitis, or appendicitis

• Is there a history of chronic

alcoholism? The history of chronic alcoholism suggests acute and chronic pancreatitis

• Is there blood in the stool? The

presence of blood in the stool would, of course, suggest peptic ulcer disease and diverticulitis

• Is there an abdominal mass? The

presence of an abdominal mass, particularly in the midepigastrium, suggests a pancreatic cyst related to chronic pancreatitis. A mass in the right lower quadrant might be related to regional ileitis or salpingitis. A mass in the left lower quadrant may be related to diverticulitis and salpingitis.