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Clinical history taking (STRUCTURE)-sandra mapa.pdf
- 1. Clinical history taking (STRUCTURE) INTRODUCTION TO CLINICAL HISTORY Importance Of Clinical History Mouthparts Compound Eyes Antennae Purpose Of Clinical History Skills Required For Taking A Clinical History Structure Of Clinical History Initiating The Session Presenting Complaint/chief Complaint (Pc/cc) History Of Presenting Complaint/history Of Present Illness (Hpc/hpi) Past Medical History (Pmhx) Drug History (Dhx) Family History (Fhx) Social History (Shx) Review Of Systems (Ros) Ideas, Concerns, Expectations (Ice) Physical Examination (Pe) STEP 3 HISTORY OF PRESENTING COMPLAINT (SOCRATES) Site Where Exactly Is The Pain? Show Me Where It Hurts. Onset When Did It Start/begin? Was It Constant Or Intermittent? Was It Gradual Or Sudden? Character What Is The Pain Like? Can You Describe The Pain? (Is It Sharp, Burning, Tight, Dull, Cramping)? Radiation Does It Radiate/move Anywhere? Associated Symptoms Is There Anything Associated With The Pain? (E.g., Breathlessness, Sweating, Nausea, Vomiting) Timing Does It Follow Any Time Pattern? How Long Does It Last? (Seconds, Days, Weeks) Exacerbating/relieving Factors Does Anything Make It Better? Does Anything Make It Worse? (E.g., Worse On Lying Down) Severity On A Scale From 1 To 10, How Severe Is Your Pain? How Is The Pain Affecting Your Life? Note The Citation Provided Is For The General Information Related To The History Of Presenting Complaint Using The Socrates Acronym. STEP 2 PRESENTING COMPLAINT/CHIEF COMPLAINT. Screening And Confirming The Complaint To Make Sure We Have The Correct Symptoms And The Patient Has Told Us Everything. Setting The Agenda Preparing The Patient For The History Of Presenting Complaint/history Of Present Illness (Hpc/hpi). Opening Question -Example: "So, You Have Chest Pain, Anything Else?" Or "So, You Have A Stomachache And Fever. Anything Else You Want To Talk About?" Opening Question How Can I Help You? What Is Troubling You? What Problems Do You Have? Note: The Citations Provided Are For The General Information Related To The Steps Involved In The Clinical History Process. STEP 1 INITIATING THE SESSION Call The Patient Into The Office/examination Room Introduce Yourself Identify The Patient Gain Consent To Speak With Them