The consultation document outlines the steps involved in a medical consultation. It begins with initiating the session which includes introducing oneself to the patient, obtaining consent, and identifying the reason for the visit. Next is gathering information such as taking a history, performing a physical exam, and ordering any necessary investigations. The doctor then makes a diagnosis and discusses management with the patient. The session closes by explaining the plan and addressing any questions or concerns. Effective communication skills are emphasized throughout the process to build rapport and properly understand the patient's perspective.

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 ?

13. History components

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