لجنة الطب البشري رؤية تنير دروب تميزكم

Clinical skills

History Taking

Done by: Hasan Zreiqat

ا صبرٌ جميل .لا تفقد صبرك مهمَا تأخر عليك الفرَج، فما بين حلمك و تحقيقه إلاا

History Taking

First of all,

We will start with the basics of clinical procedures.

Before examining the patient you should do the following steps.

1-Introducing yourself

2-Gaining consent

3-performing hand hygiene

4-rolling up your sleeves and remove your watch

5-providing privacy

:definitionsImportant skills in medical consultation and there

Open and closed question techniques: Move appropriately from

open (answer is long) to closed (yes/no) questions.

Screening: Asking if there is anything else to ensure no points are

missed

Active Listening: Utilizing wait time, non-verbal cues, facilitative

response (um... go on...)

Signposting: Progress from one section of the medical interview to

another by explaining what you want to discuss next

Facilitative Response: Nodding head, using “um, ah-ha, go on” to

encourage patient to keep talking but showing that you are

listening

Clarification: Ask patient to rephrase or check understanding of

words or statements that are unclear from the patient

Using easily understood language: Avoid using medical words

that patients will not understand

Establish sequence of events: Discover logical sequence of the

patient's story.

Incorporate patient's perspective: Discover patient's ideas,

concerns, expectations, effects on life

Develop rapport: Building the relationship with the patient so that

the doctor and patient can relate well to each other

o Accept patient's views and feelings non-judgmentally

o Use empathy, acknowledge patient's feelings

o Provide support

o Deal sensitively with patient

Involve patient: Explain to the patient the rationale for asking

certain questions.

Summarizing: Using your own words to shorten what has been

said, but still containing the main points.

Empathy: The experience of understanding another person's

condition from their perspective.

Starting consultation

o Make sure you are talking to the correct patient

o Introduce your self

o Handshake

o Look at the patient’s records and at any transfer or admission

letters before starting the conversation

The information that you should ask the patient about it:

Patient’s Profile

Personal information about patient, and that includes:

• Name • Age • Gender • Occupation

• Address • Marital status

• The way of presentation of the patient to the hospital

The presenting complaint

The primary symptom that a patient states as the reason for

seeking medical care.

History of presenting complaint

It refers to a detailed interview prompted by the chief complaint

or presenting symptom

Pain

There are principles to ask about pain (SOCRATES) which are:

o Site (somatic pain is well localized while visceral pain is diffuse)

o Onset (speed of onset)

o Character (describing the pain- dull/ sharp/ stabbing/ burning)

o Radiation (referred pain vs shifting pain vs radiating pain) o

Associated symptoms

o Timing (course- increasing, decreasing… , pattern- continuous,

episodic…)

o Exacerbating and relieving factors (activities, medications,

posture, food…)

o Severity (usually difficult to assess- because of the variations in

pain threshold- and more important in evaluating the progress of

pain)

Past history

It includes past medical and past surgical history

Allergies & Drug History

Asking about any prescribed drugs and medications

Family history

Asking about any illnesses that run in family, or about any sudden

death

Social history

Helps to understand the context of the patient’s life and possible

relevant factors

Social history

1: upbringing 2: home life 3: finance 4: house

5: occupation 6: relationship 7: sexual history 8: exercise

9: substance abuse 10.leisure 11: domestic circumstances

Patient’s perspective

Patient’s ideas and feelings of has happened to him/her

Abbreviated in FIFE

• Feelings related to illness

• Ideas on what is happening to him

• Functioning in terms of impact on daily life

• Expectations of illness and doctor

Systemic review

Uncovers symptoms that may have been forgotten (ask ‘Is there

anything you would like to tell me about?’)

Scenario :

What should you do in OSCE?

Doctor : Dr Patient: P Emergency : ER

When you enter the room you should introduce yourself to your

patient for example:

Dr: Hi, good morning I am doctor Hasan, I am your doctor for today

…. What is your name?

P: My name is Leen

Dr: May I ask you some questions please? (Gaining consent)

P: Yes, for sure

Dr: How old are you?

P: I am 20 years old

Dr: Where do you live?

P: In Amman

Dr: What do you do for work?

P: I am a student in the HU

Dr: Are you married?

P: No I am not

Dr: Why did you come to the hospital today and how?

P: I came by car to the ER because of my bad chest pain

Dr: ahaaa Is there anything else?

P: shortness of breath

Dr: Which is more sever, your shortness of breath or your chest

pain?

P: chest pain

Dr: okay leen let's talk about your chest pain

Dr: Where is the pain?

P: In the left of my chest

Dr: When did it start?

P: A week ago

Dr: Was it sudden or gradual?

P: Sudden pain

Dr: Can you describe the pain for me?

P: It is a sharp pain

Dr: Does it moves any where?

P: No

Dr: Does it come and go?

P: It comes in attacks and maybe last for 5 minutes

Dr: What makes it worse?

P: When I lay flat

Dr: What makes it better?

On a scale for 1 to 10, where 10 is the worst pain, how severe is

yours

P: 8

Dr: Is there anything you want to add

P: No doc.

Now you will summarize

Dr: So you have a sharp pain, in your left chest. It started a week

ago, it was a sudden pain, comes and goes in episodes, lying flat

makes it worse and it is 8 out of 10

Now you will ask about past medical history

Dr: Ok Lets move on to your past medical history

P: Ok

Dr: Have you been seriously ill before?

P: No

Dr: Have you been admitted to a hospital?

P: Yes

Dr: What for?

P: To remove my appendix

Dr: How long did you stay there?

P: Two days

Dr: Do you feel better after surgery ?

P: Yes

Dr: Have you had any other surgeries?

P: No, just appendectomy

Dr: Do you have any sort of diseases, blood pressure, diabetes?

P: No

Dr: Now I want to know more about your medications and allergies

P: Ok

Dr: Do you take any sort of medication?

P: No

Dr: Are you allergic to anything?

P: Yes to penicillin

Dr: Lets know more about your family …. Are your parents doing

well ?

P: Previously my father had the same pain and he made a catch to

open an occluded artery

Dr: Is there any certain illness, like blood pressure , heart attacks ,

diabetes

P: No

Dr: I would like to know more about your social life if you do not

mind

P: Ok

Dr: Do you smoke leen?

P: No

Dr: I am really sorry to ask this, but do you drink alcohol?

P: No

Dr: Do you consume illegal drugs?

P: No

Dr: Do you live in an apartment or separate house?

P: Separate house

Dr: Ok, do you have any pet or animal at home?

P: Yes, a cat

Dr: I have I cat too

Dr: Have you travelled recently?

P: No

Dr: Ok, leen what do you think that might be causing this pain

P: Maybe a problem in my heart

Dr: Aha, what concerns you about this?

P: I am worried, as I told you my father had a catch

Dr: How has this been affecting your life?

P: I was not able to go to college lately

Dr: Okay , What do you expect me to do for you ?

P: Do some examinations and test for me

Dr: Okay leen I will do my best, thank you.

P: Thank you Dr.

.إن الإتجاه الذي يبدأ مع التعلم سوف يكون من شأنهِِ أن يحُدد حياة المرء في المستقبل