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Medical History

Medical History. Dr.H.N.Sarker MBBS. FCPS (med). MACP(USA). MRCP (London). MRCPS(GLASGO) Associate professor Medicine. “Patient suffers from disease but presents with symptoms” Dr.Sarker. Cardiorespiratory. Chest pain Intermittent claudication Palpitation Ankle swelling

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Medical History

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  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” Dr.Sarker.

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

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

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

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

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

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

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

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

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

  12. The Calgary-Cambridge framework

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

  14. 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?' • 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. • 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. • Use open questioning initially; Tell me how your symptoms started?. • 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) • 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) • Well, it was here, across my chest. It was sort of tight. • And did it go anywhere else? (Clarifying) • 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) • 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) • Oh, 3 or 4 months ago. • Does anything make it worse? (Open questioning) • Well, if I go up steps or up hills that can bring it on. • What do you do? • Stop and sometimes take my puffer. • Your what? (Clarifying) • This spray the doctor gave me to put in my mouth.

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

  22. 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) • No, it was much worse this morning.

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

  24. THANK YOU

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