History Taking final.ppt
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The document provides guidance on taking a patient's medical history. It outlines the 10 components of a history that should be covered which include the present complaint, history of the complaint, review of major body systems, past medical history, and social history. Taking a thorough history is important for making an accurate diagnosis and treatment plan. The history should be taken in a respectful manner and all relevant details about the patient and their condition should be documented.
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The document provides guidance on taking a patient's medical history. It explains that taking a thorough patient history is important for systematically recording all relevant medical information. It outlines the key components of a patient history, including personal details, chief complaint, present illness history, review of systems, past medical history, family history, medication history, social history, and other relevant details. The document provides examples of questions to ask within each section and notes important points such as using open-ended questions and avoiding leading questions. It also provides tips for handling special situations and challenges that may arise during a patient interview.
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The document provides guidance on taking a patient's medical history. It explains that taking a thorough patient history is important for systematically recording all relevant medical information. It outlines the key components of a patient history, including personal details, chief complaint, present illness history, review of systems, past medical history, family history, medication history, social history, and other relevant details. The document provides examples of questions to ask within each section and notes important points such as using open-ended questions and avoiding leading questions. It also provides tips for handling special situations and challenges that may arise during a patient interview.
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As with any assessment, the chief complain is often what drives what our questions are and what clinical pathways we explore. With women’s health that approach is not any different, as we need to explore the “what was”, “what is” and “what will be” for the patient. The comprehensive assessment is one that is longer in nature and normally saved for the first visit, as if this patient will be a returning patient a more focused examine comes during their following appointments. The follow is a “blanket” comprehensive assessment that can be tweaked for any patient (Elson, 2008);
Chief complaint (is this a focused complaint or a first meeting or annual meeting)
History of present illness
Menstrual History
Age at menarche
Last menstrual period
Menstrual characteristics
Length
How long is flow
Amount of flow
Other symptoms? (breast tenderness, pelvic pain, etc)5
Pain?
Intermenstrual bleeding
Perimenopause/menopause
Bleeding pattern
Vasomotor symptoms
Contraception
Current method; is it working?
Previous method; any complications and reason for change
Cervical and vaginal cytology
Results and date of most recent pap
Hx of abnormal paps? Why? Treatment?
Infections
Hx of STD?
Hx of vaginitis (types, frequency and treatment)
Hx of PID
Fertility/infertility
Any desire for future?
Difficulty conceiving? Treatments in past?
Sexual hx
Type
Concerns about libido, orgasm, dyspareunia
Any hx of abuse? Assault?
Obstetric hx
Describe each pregnancy and outcome
Any maternal, fetal or neonatal complications?
Past medical history
Current and past illnesses
Hospital admissions
Surgical hx
GYN and Non-gyn
Medications/allergies
OTC, prescribed, herbal
Allergies to meds, food, environment and reactions?
Family hx
Significant illnesses of family
Hereditary concerns
Social hx
Relationship status
Level of education
Occupation
R.O.S.
Abdomino-pelvic
GYN
GI
GU
Breast
Others
18.Health Maintenance
Smoking, alcohol use, drug use
Diet
Supplement intake
Exercise
Regular screenings (mammo, pap, colonoscopy)
Immunizations and dates
Health maintenance is very important for all ages when related to women’s health. The following are some ideas of health maintenance for each age group (Well-Woman Recommendations, 2018);
Adolescents
If sexually active the patient should have discussion with provider on sexually transmitted diseases and contraceptive use
Drugs and alcohol use
Peer pressure with sexual situations
Childbearing
Annual blood work to identify challenges in anemia, TSH, Cholesterol and minerals.
Breast self-awareness
Reproductive health plan
Imitate partner violence
Peri-menopausal
Hormone therapy
Mammograms
Advance directives
Problems with sexual encounters (pain, dry, etc)
Menopausal
Sleep patterns
Chang ...
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The document outlines a comprehensive assessment for women's health exams. It discusses conducting a thorough history including chief complaint, menstrual, sexual, obstetric, medical, and family histories. It also discusses performing a review of systems and health maintenance screening recommendations tailored for different age groups such as adolescents, peri-menopausal, and geriatric patients. The comprehensive exam is recommended for initial visits to establish a baseline, while focused exams are used for follow-up appointments.
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Medical history taking in pregnant women.
Proper history taking leads to a good diagnosis and it helps to avoid many complications.
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This document outlines the components of a gynaecological history taking, which includes gathering general information about the patient, details about their presenting complaint, menstrual history, pelvic pain, vaginal discharge, sexual history, previous medical history, and family history. Key areas to ask about are age of menarche, length and regularity of menstrual cycles, last pap smear, contraceptive use, menopausal symptoms if relevant, previous pregnancies or surgeries, and current medical conditions or medications. A thorough gynaecological history supports an accurate diagnosis and appropriate treatment plan.
Geriatric Population. Geriatric Palliative and End-of-Life Care.
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After practicing as a Geriatric Clinician for over a decade what I know for sure is: Life is a tremendous gift. 100% of us are going to die. If you don't communicate your end-of-life plan, then you should plan on dying badly.
In The Cost of Dying: End-of-Life Care on CBS 60 minutes Steve Kroft interviews Doctor Ira R. Byock. “Families cannot imagine that there could be anything worse than their loved one dying, but in fact there are things worse, generally it’s having someone you love die badly.” ~Doctor Ira Byock
“Dr. Byock what do you mean dying badly?” ~Mr. Kroft
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Let’s explore how the end-of-life decision occurs?
For Doctors
Bernacki & Block (2014) found in their review and synthesis of best practices that physician attitudes, training, and perceptions of feeling inadequate in managing the emotional and behavioral reactions of patients all play a role. A majority of trainees were not taught how to communicate and they express strong desires to learn more. Physician barriers also include not addressing psychosocial concerns, placing focus on diagnoses, treatments, and procedures during discussions about the medical care at the end-of-life.
For Patients
Bernacki & Block (2014) found that patients who do bring up dying concerns with their physicians often meet barriers and often are not aware that they are at the end-of-life. Patients that have not set goals based on meaningful conversations about their desires may overuse life-prolonging treatment and underuse services that support quality of life.
Conclusion
Bernacki & Block (2014) found that there is a large body of evidence demonstrating that early discussions of serious illness care goals are associated with:
♛ beneficial outcomes for patients,
♛ no harmful adverse effects, and
♛ potential cost savings.
Apply & Do
To prevent dying badly start early conversations, enhance your knowledge and establish goals. Dreams are only dreams until you write them down. When you write dreams down then they become goals.
Do ♛ The Conversation Project a collaboration with the Institute for Healthcare Improvement. http://theconversationproject.org/starter-kit/intro/
Do your conversation kit now and make your loved ones aware of your wishes.
Wishing you the very best, Michelle
Bernacki RE, Block SD, for the American College of Physicians High Value Care Task Force. Communication About Serious Illness Care Goals: A Review and Synthesis of Best Practices. JAMA Intern Med. 2014;174(12):1994-2003.
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This document provides guidance on effective communication and history taking with surgical patients. It outlines the importance of history taking in reaching diagnoses and treatment plans. It describes the components of an effective patient history, including personal data, chief complaints, present and past medical histories, habits, and family history. It provides guidelines for asking open-ended questions, handling sensitive topics, and overcoming communication barriers. The document emphasizes creating a safe environment for patients and using active listening techniques.
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As with any assessment, the chief complain is often what drives what our questions are and what clinical pathways we explore. With women’s health that approach is not any different, as we need to explore the “what was”, “what is” and “what will be” for the patient. The comprehensive assessment is one that is longer in nature and normally saved for the first visit, as if this patient will be a returning patient a more focused examine comes during their following appointments. The follow is a “blanket” comprehensive assessment that can be tweaked for any patient (Elson, 2008);
Chief complaint (is this a focused complaint or a first meeting or annual meeting)
History of present illness
Menstrual History
Age at menarche
Last menstrual period
Menstrual characteristics
Length
How long is flow
Amount of flow
Other symptoms? (breast tenderness, pelvic pain, etc)5
Pain?
Intermenstrual bleeding
Perimenopause/menopause
Bleeding pattern
Vasomotor symptoms
Contraception
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Previous method; any complications and reason for change
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Infections
Hx of STD?
Hx of vaginitis (types, frequency and treatment)
Hx of PID
Fertility/infertility
Any desire for future?
Difficulty conceiving? Treatments in past?
Sexual hx
Type
Concerns about libido, orgasm, dyspareunia
Any hx of abuse? Assault?
Obstetric hx
Describe each pregnancy and outcome
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Past medical history
Current and past illnesses
Hospital admissions
Surgical hx
GYN and Non-gyn
Medications/allergies
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Family hx
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Hereditary concerns
Social hx
Relationship status
Level of education
Occupation
R.O.S.
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GI
GU
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Smoking, alcohol use, drug use
Diet
Supplement intake
Exercise
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Immunizations and dates
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Adolescents
If sexually active the patient should have discussion with provider on sexually transmitted diseases and contraceptive use
Drugs and alcohol use
Peer pressure with sexual situations
Childbearing
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Breast self-awareness
Reproductive health plan
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Hormone therapy
Mammograms
Advance directives
Problems with sexual encounters (pain, dry, etc)
Menopausal
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The document outlines a comprehensive assessment for women's health exams. It discusses conducting a thorough history including chief complaint, menstrual, sexual, obstetric, medical, and family histories. It also discusses performing a review of systems and health maintenance screening recommendations tailored for different age groups such as adolescents, peri-menopausal, and geriatric patients. The comprehensive exam is recommended for initial visits to establish a baseline, while focused exams are used for follow-up appointments.
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Proper history taking leads to a good diagnosis and it helps to avoid many complications.
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This document outlines the components of a gynaecological history taking, which includes gathering general information about the patient, details about their presenting complaint, menstrual history, pelvic pain, vaginal discharge, sexual history, previous medical history, and family history. Key areas to ask about are age of menarche, length and regularity of menstrual cycles, last pap smear, contraceptive use, menopausal symptoms if relevant, previous pregnancies or surgeries, and current medical conditions or medications. A thorough gynaecological history supports an accurate diagnosis and appropriate treatment plan.
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After practicing as a Geriatric Clinician for over a decade what I know for sure is: Life is a tremendous gift. 100% of us are going to die. If you don't communicate your end-of-life plan, then you should plan on dying badly.
In The Cost of Dying: End-of-Life Care on CBS 60 minutes Steve Kroft interviews Doctor Ira R. Byock. “Families cannot imagine that there could be anything worse than their loved one dying, but in fact there are things worse, generally it’s having someone you love die badly.” ~Doctor Ira Byock
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“Dying suffering, dying connected to machines, denial of death at some point becomes a delusion and we start acting in ways that make no sense whatsoever.” ~Doctor Ira Byock
A majority of Americans say they want to die at home. Why is this not happening?
Place of death should be regarded as an essential goal in end-of-life care.
Let’s explore how the end-of-life decision occurs?
For Doctors
Bernacki & Block (2014) found in their review and synthesis of best practices that physician attitudes, training, and perceptions of feeling inadequate in managing the emotional and behavioral reactions of patients all play a role. A majority of trainees were not taught how to communicate and they express strong desires to learn more. Physician barriers also include not addressing psychosocial concerns, placing focus on diagnoses, treatments, and procedures during discussions about the medical care at the end-of-life.
For Patients
Bernacki & Block (2014) found that patients who do bring up dying concerns with their physicians often meet barriers and often are not aware that they are at the end-of-life. Patients that have not set goals based on meaningful conversations about their desires may overuse life-prolonging treatment and underuse services that support quality of life.
Conclusion
Bernacki & Block (2014) found that there is a large body of evidence demonstrating that early discussions of serious illness care goals are associated with:
♛ beneficial outcomes for patients,
♛ no harmful adverse effects, and
♛ potential cost savings.
Apply & Do
To prevent dying badly start early conversations, enhance your knowledge and establish goals. Dreams are only dreams until you write them down. When you write dreams down then they become goals.
Do ♛ The Conversation Project a collaboration with the Institute for Healthcare Improvement. http://theconversationproject.org/starter-kit/intro/
Do your conversation kit now and make your loved ones aware of your wishes.
Wishing you the very best, Michelle
Bernacki RE, Block SD, for the American College of Physicians High Value Care Task Force. Communication About Serious Illness Care Goals: A Review and Synthesis of Best Practices. JAMA Intern Med. 2014;174(12):1994-2003.
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原版定制【微信:bwp0011】《(uofm毕业证书)美国密歇根大学毕业证学位证书》【微信:bwp0011】成绩单 、雅思、外壳、留信学历认证永久存档查询，采用学校原版纸张、特殊工艺完全按照原版一比一制作（包括：隐形水印，阴影底纹，钢印LOGO烫金烫银，LOGO烫金烫银复合重叠，文字图案浮雕，激光镭射，紫外荧光，温感，复印防伪）行业标杆！精益求精，诚心合作，真诚制作！多年品质 ,按需精细制作，24小时接单,全套进口原装设备，十五年致力于帮助留学生解决难题，业务范围有加拿大、英国、澳洲、韩国、美国、新加坡，新西兰等学历材料，包您满意。
【业务选择办理准则】
一、工作未确定，回国需先给父母、亲戚朋友看下文凭的情况，办理一份就读学校的毕业证【微信bwp0011】文凭即可
二、回国进私企、外企、自己做生意的情况，这些单位是不查询毕业证真伪的，而且国内没有渠道去查询国外文凭的真假，也不需要提供真实教育部认证。鉴于此，办理一份毕业证【微信bwp0011】即可
三、进国企，银行，事业单位，考公务员等等，这些单位是必需要提供真实教育部认证的，办理教育部认证所需资料众多且烦琐，所有材料您都必须提供原件，我们凭借丰富的经验，快捷的绿色通道帮您快速整合材料，让您少走弯路。
留信网认证的作用:
1:该专业认证可证明留学生真实身份
2:同时对留学生所学专业登记给予评定
3:国家专业人才认证中心颁发入库证书
4:这个认证书并且可以归档倒地方
5:凡事获得留信网入网的信息将会逐步更新到个人身份内，将在公安局网内查询个人身份证信息后，同步读取人才网入库信息
6:个人职称评审加20分
7:个人信誉贷款加10分
8:在国家人才网主办的国家网络招聘大会中纳入资料，供国家高端企业选择人才
【关于价格问题（保证一手价格）】
我们所定的价格是非常合理的，而且我们现在做得单子大多数都是代理和回头客户介绍的所以一般现在有新的单子 我给客户的都是第一手的代理价格，因为我想坦诚对待大家 不想跟大家在价格方面浪费时间
对于老客户或者被老客户介绍过来的朋友，我们都会适当给一些优惠。
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History Taking final.ppt
- 2. Why do we take history from the patient?
- 3. What would happen if we do not make a diagnosis? or if we made the wrong diagnosis?
- 4. How do we take history?
- 5. Set up of history taking In the outpatient clinic In the inpatient clinic
- 6. Components of the History The present complaint The history of the present complaint Remaining questions of abnormal system Review of systems Past medical history Past surgical history Drug history Immunizations Family history Social history & habits
- 7. ALWAYS INTRODUCE YOURSELF TO THE PATIENT AND EXPLAIN TO HIM OR HER WHAT YOU ARE GOING TO DO. GET A CHAPERON WHEN YOU INTERVIEW A FEMALE PATIENT.
- 8. ALWAYS RECORD PATIENT’S Name Age Sex Marital status Occupation Address Date of interview
- 9. 1-Present complaint In patient’s own words with duration. “What are you complaining of?” “What is the problem?” “What is the matter?”
- 10. 2-History of the present complaint EXAMPLE: ABDOMINAL PAIN Site Time and mode of onset Nature Duration Severity Radiation Progression/end Relieving factors Exacerbating factors Cause
- 11. 3-Remaining questions of abnormal system
- 12. Is it time to make a provisional diagnosis? What is a diagnosis?
- 13. Diagnosis Any diagnosis consists of Anatomical part + Pathological part Examples: Breast cancer Peptic ulcer Fracture femur
- 14. Differential diagnosis or working diagnosis Most likely why? Less likely why? Least likely why?
- 15. 4-Review of systems The Gastro-intestinal system The Respiratory system The Cardiovascular system The Urogenital system The Nervous system The Musculoskeletal system
- 16. Gastro-intestinal system Appetite Diet Weight Teeth and taste Swallowing Regurgitation Fatulance Heartburn Vomiting Haematemesis Abdominal PAIN Abdominal distension Defecation Change of color of skin
- 18. The Cardiovascular system CHEST PAIN Dyspnoea Orthopnoea Palpitations Cough and sputum Dizziness and headache Ankle swelling Peripheral vascular symptoms
- 19. The Urogenital system Pain Oedema Thirst Micturition Urine Scrotum and urethra Menstruation Pregnancies Breasts Secondary sex characteristics
- 20. The Nervous system Mental state Conscious level Fits TIAS= transient ischemic attacks Loss of sensations Paraesthesiae (pins and needles)
- 21. The musculoskeletal system Pain Swelling Limitation of movements of any joint
- 22. 5-Past medical history Any hospitalization TB = Tuberculosis DM = Diabetes mellitus Asthma Rheumatic fever Contact with patients with hepatitis or aids
- 23. 6-Past surgical history Previous operations Blood transfusion Any complications with anesthesia Bleeding tendencies
- 24. 7-Drug history Steroids Insulin Antihypertensive drugs Hormone replacement therapy
- 25. 8-Immunizations DPT = diphtheria, pertussus, tetanus Measles Mumps Rubella Poliomyelitis TB Smallpox Typhoid
- 26. 9-Family history Health and age or cause of death of patient’s parents ,brothers and sisters
- 27. 10-Social history & habits Marital status Hazards of occupation Social status- type of residence Travel abroad-dates Smoke Drinks Any unusual?
- 28. Summary Patient’s name, age and sex. Complaint and the most important positive characteristics of his/her complaint The most important negative features of his complaint.
- 29. Analysis of the differential diagnosis Review the list you made earlier
- 30. What have we gained from the history taking? To make a diagnosis To formulate a complete picture about this patient which will enable you to plan his or her management
- 31. THANK YOU