236 2021 u3 history taking VOC

A medical history is a report that includes information gainedfrom a patient's medically relevant recollections e.g., symptoms, concerns, past diseases and questioning regarding their co

HISTORY TAKING

UNIT 3 – VOCABULARY & READING (2 hours)

ENGLISH IN MEDICINE 2 – GENERAL PRACTITIONER Y2

Editor: Nguyen Hoang Quynh Mai Email: 1004quynhmai@gmail.com

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

 What _ the problem?

 What you here?

 How long ?

 When did ?

 Where ?

 Can you tell me _?

Starting the interview Ask about the chief complaint Ask about duration Ask about location

2 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

WHAT SYMPTOM IS IT?

2 ASKING ABOUT SYMPTOMS

3 HISTORY TAKING OUTLINE

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

VIDEO: https://www.youtube.com/watch?v=9om2tedf9oo

What did the doctor ask his patient?

(Put items in the right order)

1 How would you like me to …?

2 Anything we discussed remain confidential within the medical team as well.

3 Tell me a bit about what has been going on.

4 I see.

5 Would you say …?

6 Overall you’ve made the right decision by coming in.

3 HISTORY TAKING OUTLINE

7 You’ve mentioned a few things already Let’s start with …

8 Just let me know if you’d like, okay?

9 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?

1 Opening the conversation: intro., confirm pt., gain consent

2 Presenting complaint

3 History of presenting complaint: SOCRATES

4 Past medical history

5 Drug history & allergies

6 Family history

7 Social history: bad habits, diet, exercise, occupation

8 Systemic screen

9 Closing the conversation: thanks, summaries

3 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

3 HISTORY TAKING OUTLINE

4 EXERCISES

TAKING HISTORY IS NOT JUST ASKING QUESTIONS!

WRITING PRACTICE

1 What is SOCRATES? (3-5 sentences)

2 What are some questions to ask about symptoms that the patient is having? (3-5 sentences)

3 Introduce the role and main steps of history taking (at least 2 paragraphs)

10 MCQS ON KAHOOT

& ANSWERS