Introduction to History Taking

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Introduction to History Taking

  1. 1. Introduction tomedical history taking
  2. 2. Before you start to take anyhistory…..1. Wash hands2. Establish initial rapport• Greet patient and obtain patient’s name and age• Introduce self and clarify role• Explain nature of interview, seek consent• Demonstrate interest and respect, attend to patient’s physical comfort(taken from the Calgary-Cambridge Guide)
  3. 3. • What is a history?A patient narrative facilitated by the doctor or medical studentA dialogueInformation given by the patient and gathered by the interviewer using their generic communication skillsRecorded (not taken)in a standard way
  4. 4. • Why is information recorded in a standard way?As a learner, to check you don’t miss anything!As a clinician - to facilitate diagnosis - to communicate information effectively with your colleagues
  5. 5. Basic Structure of Any MedicalHistory• PC Presenting complaint• HPC History of Presenting Complaint• PMH Past Medical History• DH/Med Drug History• FH Family History• SH Social History• SE Systems Enquiry• ICE Ideas, concerns, expectations
  6. 6. Basic Structure of Any MedicalHistory• PC Presenting complaint Brief description of the presenting problem or symptom (may be verbatim)• HPC History of Presenting Complaint - time scale - describe and explore presenting symptoms - review of all symptoms of relevant body system - may include important positives and negatives from PMH, FH, SH - may include the patient’s perspective
  7. 7. • PMHPast Medical History - relevant to presenting complaint - specific major operations - specific major illnesses - general health• Drug history - current prescribed medication - over the counter (OTC) - homeopathic or health supplements (CAM) - specific medications for the presenting body system
  8. 8. • Allergies - NKDA No known drug allergies - Allergies Drug and reaction• FH Family History• SH Social History - Occupation - Household and housing - Lifestyle factors including alcohol, smoking, exercise -Activities of daily living
  9. 9. • ICE Ideas, concerns, expectations The patient’s view of their illness. Feelings, thoughts, impact. (Will be covered more in PPD next term)• SE Systemic enquiry (or Review of systems) A check list covering key symptoms within all major body systems (covered in Stage 2 and Phase 2)• Summary (covered in Stage 2)
  10. 10. Further reading on History Taking read about this aspect of communication in moreIf you want to detail, any of the following would be a good starting point:• Silverman, Kurtz and Draper. Skills for communicating with patients, Chapter 3., pp 70-85 (Exploration of problems)• Lloyd and Bor. Communication skills for medicine, Chapter 2., (Basic communication skills)• Myerscough and Ford. Talking with patients Chapter 3, (Conducting an interview)• Two papers on history taking by DR Nayankumar Shah from studentBMJ in September and October 2005 ( http://www.studentbmj.com/issues/05/09/education/314.php and http://www.studentbmj.com/issues/05/10/education/358.php )• Macleod`s Clinical Examination, 12th ed, Churchill Livingstone.

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