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Effective Communication Skills

• Use open questions to encourage patients to share more information about their problem
• Use prompts like "I see", "I understand", "Tell me more about that" to make the patient feel heard
• Nod your head to show you're considering their ideas and opinions
• Repeat the last statement made by the patient with a questioning tone to ensure understanding
• Take notes without interrupting the patient

Eliciting Information

• Ask patients about their history, including medical, surgical, family, psychosocial, and drug history
• Clarify any unclear information by asking follow-up questions
• Use the patient's words to summarize their information
• Give the patient time to digest the information before moving forward

Parts of History

• Demographic Data: name, age, gender, race, marital status, residence, occupation, religion
• Chief Complaint: 1-2 symptoms that brought the patient to the hospital, duration
• History of Present Illness: detailed story of the condition in the patient's words
• Systemic Review: gastrointestinal, cardiovascular, respiratory, urogenital, neurological, musculoskeletal, and integumentary systems
• Past History: medical, surgical, family, social, and drug history

Symptomatology

• Pain: site, quality, intensity, timing, aggravating and relieving factors, referral, radiation, and migration
• Cough: frequency, change of posture, productive or dry, sputum color and amount, associated symptoms
• Dyspnea: shortness of breath, classification, orthopnea, exertional dyspnea, paroxysmal nocturnal dyspnea
• Dysphagia: difficulty swallowing, painful or painless, to solid food, fluid, or saliva
• Weight Loss: amount, period, significant weight loss (>10% of body weight in 3 months)
• Appetite: increased, decreased, or remained the same

Vomiting

• Quantity or volume, frequency, quality, associated blood, color, and taste
• Projective, self-induced, or effortless vomiting, timing, and relieving pain
• Associated symptoms, preceding symptom or factor, and flatulence

Jaundice

• Yellowish discoloration of skin and eyes, progressive or intermittent, painless or painful
• Itching, dark-colored urine, and pale stools in obstructive jaundice
• Associated symptoms, such as loss of appetite, weight loss, and dyspepsia

Defaecation

• Bowel habits: frequency, color, consistency, amount, smell, and specific gravity
• Diarrhea: increased frequency, watery consistency, large amount, and urgency
• Constipation: absolute constipation, obstipation, bleeding per rectum, and types of bleeding

Communication Skills

• Room environment: quiet, air-conditioned, well-lit, and one patient at a time
• Principles: introduce yourself, shake hands, make the patient sit comfortably, ask about companions, establish a relationship, and use simple clear language
• Listen well, don't interrupt, clarify patient symptoms, achieve empathy, and provide information in small packages
• Use open questions, probing questions, closed questions, leading questions, double-barreled questions, and difficult questions