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History components
- 1. The consultation Dr. Abeer Abdulkareem
- 2. The consultation The occasion when a person who is ill seeks the advice of a doctor whom he trusts. (in the consulting room) .
- 3. Consultation • History taking • Physical examination • Investigation • Diagnosis • Management
- 5. Closing the session explain and planning Physical examination Gathering information Initiating the session Building the relationshipProviding structure Calgary Cambridge framework
- 6. Calgary Cambridge framework Initiating the session Gathering Information Physical examination Share/explain and planning Closing the session Providing structure Making the organisation overt Attending to flow Building the relationship Using appropriate non verbal behaviour Developing rapport Involving the patient Initiating the session • Preparation: introduce yourself, identity of patient (Identifying Data: PH Includes age, gender, marital status, and occupation ,consent and explanation) • Establishing initial rapport: (communication skills) • Identifying the reason for the consultation: open question, listen attentively, summary Gathering information • Exploration of the patients problems to discover the Biomedical perspective – Sequence of events, Symptom analysis Relevant systems review CC/HPI, PM/SH, FH, DH, SR • Patients’ perspective ICEE Closing the session Ensuring appropriate point of closure Forward planning - safety netting
- 7. Communication skills Communication is exchange of the knowledge through : 1. Sitting 2. Speaking 3. Body language 4. Environment.
- 8. miling ummarize pen posture. orward lean. aking notes ouch ye contact. odding.
- 9. Always listen to the patient they might be telling you the diagnosis
- 10. Appropriate Vs inappropriate body language
- 11. Which body languages are included in this picture ?
- 12. Which body languages are included in this picture ?
- 14. PRESENT HISTORY SOCIAL HISTORY PAST HISTORY COMPLAINT DRUG HISTORY FAMILY HISTORY Review of systems ICEE Communication skills
- 15. PRESENT HISTORY SOCIAL HISTORY PAST HISTORY COMPLAINT DRUG HISTORY FAMILY HISTORY Review of systems ICEE Communication skills
- 16. Complaint ONSET: How quickly did the symptoms emerge? (Acute or chronic) COURSE: Is it intermittent ? OR Progressive ? DURATION
- 17. Major Respiratory system complaints Cough and Sputum
- 18. Major Respiratory system symptoms Cough Expectoration (Sputum) Haemoptysis Dyspnoea Wheeze Chest pain
- 19. PRESENT HISTORY SOCIAL HISTORY PAST HISTORY COMPLAINT DRUG HISTORY FAMILY HISTORY Review of systems ICEE Communication skills
- 20. S O C R AAA T S SITE ONSET CHARACTER RADIATION AGGRAVATING FACTORS ALLEVIATING FACTORS ASSOCIATED SYMPTOMS TIMING SEVERITY
- 21. PRESENT HISTORY SOCIAL HISTORY PAST HISTORY COMPLAINT DRUG HISTORY FAMILY HISTORY Review of systems ICEE Communication skills
- 22. I.C.E.E. Patient’s ideas (i.e. beliefs) Patient’s concerns (i.e. worries) regarding each problem Patient’s expectations (i.e., goals, what help the patient had expected for each problem) Effects: how each problem affects the patient’s life
- 23. Personal and social history • Marital status. • Level of education. • History of travelling . • Alcohol, smoking. • Housing. • Occupation and job security. • Social or financial problems.
- 24. PRESENT HISTORY SOCIAL HISTORY PAST HISTORY COMPLAINT DRUG HISTORY FAMILY HISTORY Review of systems ICEE Communication skills
- 25. Family history • History of hereditary diseases. •History of similar condition. •History of chronic diseases( information about heart disease, hypertension, diabetes& asthma)
- 26. PRESENT HISTORY SOCIAL HISTORY PAST HISTORY COMPLAINT DRUG HISTORY FAMILY HISTORY Review of systems ICEE Communication skills
- 27. Past medical and surgical history • previous hospital admissions • past operations or investigations • chronic diseases or major illnesses (DM, HTN, BA) • accidents and injuries
- 28. PRESENT HISTORY SOCIAL HISTORY PAST HISTORY COMPLAINT DRUG HISTORY FAMILY HISTORY Review of systems ICEE Communication skills
- 29. Drug history • medication the patient is taking (prescribed and over the counter) • medication that the patient is known to be sensitive to This information is needed because: • medication may be the cause of the presenting problem • the patient may be suffering from side effects
- 30. PRESENT HISTORY SOCIAL HISTORY PAST HISTORY COMPLAINT DRUG HISTORY FAMILY HISTORY Review of systems ICEE Communication skills
- 31. PRESENT HISTORY SOCIAL HISTORY PAST HISTORY COMPLAINT DRUG HISTORY FAMILY HISTORY Review of systems ICEE Communication skills
- 32. Review of systems Respiratory system (cough, sputum, hemoptysis, dyspnea) Cardiovascular system (palpitation, edema, chest pain) GIT (vomiting, diarrhea. Constipation, abdominal pain)
- 33. THE HOSPITAL CLERKING MODEL • HPC History of Present Complaint • PMH Past Medical History • DRUGS Medication • FH Family History • SH Social History • DQ Direct Questions • EXAM Examination • Inx Investigation • D Diagnosis