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Medical History Dr.H.N.Sarker MBBS. FCPS (med). MACP(USA). MRCP (London). MRCPS(GLASGO) Associate professor Medicine.

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Presentation on theme: "Medical History Dr.H.N.Sarker MBBS. FCPS (med). MACP(USA). MRCP (London). MRCPS(GLASGO) Associate professor Medicine."— Presentation transcript:

1 Medical History Dr.H.N.Sarker MBBS. FCPS (med). MACP(USA). MRCP (London). MRCPS(GLASGO) Associate professor Medicine

2 “Patient suffers from disease but presents with symptoms” “Patient suffers from disease but presents with symptoms”Dr.Sarker.

3 Cardiorespiratory Cardiorespiratory Chest pain Chest pain Intermittent claudication Intermittent claudication Palpitation Palpitation Ankle swelling Ankle swelling Orthopnoea Orthopnoea

4 Cardiorespiratory Nocturnal dyspnoea Nocturnal dyspnoea Shortness of breath Shortness of breath Cough with or without sputum Cough with or without sputum Haemoptysis Haemoptysis

5 Gastrointestinal Gastrointestinal Abdominal pain Abdominal pain Dyspepsia Dyspepsia Dysphagia Dysphagia Nausea and/or vomiting Nausea and/or vomiting Change in appetite Change in appetite

6 Gastrointestinal Weight loss or gain Weight loss or gain Bowel pattern and any change Bowel pattern and any change Rectal bleeding Rectal bleeding Jaundice Jaundice

7 Genitourinary Genitourinary Haematuria Haematuria Nocturia Nocturia Frequency Frequency Dysuria Dysuria Menstrual irregularity - women Menstrual irregularity - women Urethral discharge - men Urethral discharge - men

8 Locomotor Joint pain Joint pain Joint swelling Joint swelling Change in mobility Change in mobility

9 Neurological Neurological Seizures Seizures Collapse or blackouts Collapse or blackouts Dizziness and loss of balance Dizziness and loss of balance Vision Vision Hearing Hearing Transient loss of function (vision, speech, sight) Transient loss of function (vision, speech, sight)

10 Neurological Paraesthesiae Paraesthesiae Weakness Weakness Wasting Wasting Spasms and involuntary movements Spasms and involuntary movements Pain in limbs and back Pain in limbs and back Headache Headache

11 Traditional history-taking model Presenting complaint Presenting complaint History of presenting complaint History of presenting complaint Past medical history Past medical history Drug history-Allergy history Drug history-Allergy history Family history Family history Social history Social history Systems review Systems review

12 The Calgary-Cambridge framework

13 Initiating the session Initiating the session Begin by greeting the patient and obtaining their name. Begin by greeting the patient and obtaining their name. Introduce yourself, your role, and the nature of the interview. Introduce yourself, your role, and the nature of the interview. If appropriate, obtain verbal consent for the interview. If appropriate, obtain verbal consent for the interview.

14 Communication skills in the medical interview Communication skills in the medical interview Open questions allow patients 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?'

15 Reflecting questions help to develop or expand topics, e.g. 'Can you tell me more about your family?' Reflecting questions help to develop or expand topics, e.g. 'Can you tell me more about your family?' Active listening encourages further dialogue, e.g. 'Go on,' 'I see,' 'Hmm' etc. Active listening encourages further dialogue, e.g. 'Go on,' 'I see,' 'Hmm' etc. Requesting clarification encourages further detail, e.g. 'How do mean?', 'In what way?' etc. Requesting clarification encourages further detail, e.g. 'How do mean?', 'In what way?' etc. Summarising ensures accurate understanding, e.g. 'Tell me if I've got this right.' Summarising ensures accurate understanding, e.g. 'Tell me if I've got this right.'

16 Gathering information Encourage the patient to tell the story in their own words, from beginning to end. Encourage the patient to tell the story in their own words, from beginning to end. Use open questioning initially; Tell me how your symptoms started?. Use open questioning initially; Tell me how your symptoms started?. Move on to use closed questions for details. Move on to use closed questions for details.

17 Open and closed questions Both types of question have their place. Can we start with you telling me what has happened to bring you into hospital? (Opening) Can we start with you telling me what has happened to bring you into hospital? (Opening) Well, I've been getting this funny feeling in my chest over the last few months. It's been getting worse and worse but it was really awful this morning. I got really breathless and felt someone was crushing me. Well, I've been getting this funny feeling in my chest over the last few months. It's been getting worse and worse but it was really awful this morning. I got really breathless and felt someone was crushing me.

18 Open and closed questions Tell me a bit more about the crushing feeling. (Open questioning) Tell me a bit more about the crushing feeling. (Open questioning) Well, it was here, across my chest. It was sort of tight. Well, it was here, across my chest. It was sort of tight. And did it go anywhere else? (Clarifying) And did it go anywhere else? (Clarifying) No. Well, may be up here in my neck. No. Well, may be up here in my neck.

19 Open and closed questions So what you are saying is that you had this tight pain in your chest this morning that went on a long time and you felt it in your neck? (Summarizing). You said you've had the pain for the last few months. Can you tell me more? (Reflecting and open questioning) So what you are saying is that you had this tight pain in your chest this morning that went on a long time and you felt it in your neck? (Summarizing). You said you've had the pain for the last few months. Can you tell me more? (Reflecting and open questioning) Well, it was the same but not that bad, though it's been getting worse recently. Well, it was the same but not that bad, though it's been getting worse recently.

20 Open and closed questions Can you remember when it first started? (Clarifying) Can you remember when it first started? (Clarifying) Oh, 3 or 4 months ago. Oh, 3 or 4 months ago. Does anything make it worse? (Open questioning) Does anything make it worse? (Open questioning) Well, if I go up steps or up hills that can bring it on. Well, if I go up steps or up hills that can bring it on. What do you do? What do you do? Stop and sometimes take my puffer. Stop and sometimes take my puffer. Your what? (Clarifying) Your what? (Clarifying) This spray the doctor gave me to put in my mouth. This spray the doctor gave me to put in my mouth.

21 Can you show me it, please? Can you show me it, please? OK. OK. And what does it do? (Clarifying) And what does it do? (Clarifying) Well, it takes the pain away, but I get an awful headache with it. Well, it takes the pain away, but I get an awful headache with it.

22 Open and closed questions Open and closed questions So, for a few months you've had this tightness in your chest, which gets worse going up hills and upstairs and which goes away if you use your spray. But today it came on and lasted longer but felt the same. Have I got that right? (Summarizing) So, for a few months you've had this tightness in your chest, which gets worse going up hills and upstairs and which goes away if you use your spray. But today it came on and lasted longer but felt the same. Have I got that right? (Summarizing) No, it was much worse this morning. No, it was much worse this morning.

23 Past medical history Past medical history Drug history-Allergy history Drug history-Allergy history Family history Family history Social history Social history Systems review Systems review

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