Podcast
Questions and Answers
What is Ali's temperature in Celsius?
What is Ali's temperature in Celsius?
What is Ali's respiratory rate?
What is Ali's respiratory rate?
What is the blood pressure criterion for diagnosing hypertension?
What is the blood pressure criterion for diagnosing hypertension?
What is the correct management for Ali's condition?
What is the correct management for Ali's condition?
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Why does the patient not need referral?
Why does the patient not need referral?
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When should antibiotics be provided to children with AOM?
When should antibiotics be provided to children with AOM?
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What is a characteristic of hypertensive emergency?
What is a characteristic of hypertensive emergency?
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What is the definition of resistant hypertension?
What is the definition of resistant hypertension?
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Why is hypertensive urgency a concern?
Why is hypertensive urgency a concern?
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What category of blood pressure does Ali's blood pressure fall into?
What category of blood pressure does Ali's blood pressure fall into?
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Study Notes
History Taking
- Confidentiality and respect for patient privacy are essential
- Effective questioning techniques include:
- Simple and clear questions
- Avoiding medical terms
- Open, leading, and direct questions
- Summarizing questions
Complete History Taking
Personal History
- Full name
- Age
- Sex
- Address
- Marital status
- Occupation
Chief Complaint
- The main reason for visiting a physician
- Recorded in the patient's own words
Present History
- Elaboration on the chief complaint in detail
- Associated symptoms in chronological order
- Negative information included to exclude other possibilities
- System review:
- Respiratory system
- Cardiovascular system
- Gastrointestinal system
- General system
Past History
- Medical problems (e.g., heart attack, asthma, diabetes)
- Past surgical/operation history
- History of trauma/accidents
Family History
- Previous similar illnesses in the family (e.g., hereditary diseases)
Psycho-Social History
- Smoking history
- Drinking history
- Occupation
- Education background
- History of psychiatric disease
Other Relevant History
- Gynaecological/obstetric history (if female)
- Immunization history (if a small child)
- Travel and sexual history (if STI or infectious disease)
Patient-Centred Method
- Greater patient satisfaction
- Greater doctor satisfaction
- Better patient adherence
- Improved patient outcomes
- Higher quality of self-reporting
- Fewer malpractice claims
- Positive impact on healthcare utilization costs
- Greater physician detection
Clinical Approach
History
- Relevant information gained from the patient
Examination
- General examination including vital signs
Investigation
- Only relevant investigations requested
Diagnosis
- Based on previous steps
Comprehensive Management
- Including health education, non-pharmacological and pharmacological management
Follow-up
- To assess patient compliance and degree of improvement
Importance of History Taking
- Essential skill for decision making
- Useful for making a diagnosis before performing a physical examination
Acute Otitis Media (AOM)
- Management:
- Watching and waiting for children with non-severe AOM
- Antibiotics provided for severe cases or worsening symptoms
- Referral for severe systemic infection, recurrent AOM, or failure to improve
Hypertension
- Persistent elevation of blood pressure:
- ≥ 140 systolic and ≥ 90 diastolic
- Categories of BP in adults:
- Normal BP
- Elevated BP
- Hypertension (stage 1 and 2)
- Resistant hypertension
- Hypertensive urgency
- Hypertensive emergency
- Called a silent killer due to its contribution to cardiovascular risk
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Description
This quiz assesses your knowledge of taking a complete medical history, including personal history, chief complaint, and present history. Learn how to ask effective questions and respect patient privacy.
