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Questions and Answers
What is the primary purpose of history taking in a medical context?
What is the primary purpose of history taking in a medical context?
- To perform a physical examination
- To prescribe medication
- To conduct laboratory investigations
- To determine the etiology of a patient's illness (correct)
What should be the basis of taking true history?
What should be the basis of taking true history?
- Good communication between patient and doctor (correct)
- Physical examination.
- The doctor's experience.
- Number of questions that doctor make to patient
Which of the following is NOT a suggested element of how to greet your patient?
Which of the following is NOT a suggested element of how to greet your patient?
- Display confidence
- Greet the patient by name
- Make eye contact
- Discuss personal matters to build rapport (correct)
Which of the following is NOT considered a core component of history taking?
Which of the following is NOT considered a core component of history taking?
In personal history-taking, what aspect is 'occupation' categorized under?
In personal history-taking, what aspect is 'occupation' categorized under?
Why is it important to inquire about 'special habits' during personal history taking?
Why is it important to inquire about 'special habits' during personal history taking?
A patient reports smoking 2 packs of cigarettes per day for 15 years. What is their pack-year history?
A patient reports smoking 2 packs of cigarettes per day for 15 years. What is their pack-year history?
When documenting a patient's presenting complaint, what is a crucial element to include?
When documenting a patient's presenting complaint, what is a crucial element to include?
What aspects are important in the history of presenting complaint?
What aspects are important in the history of presenting complaint?
What does the mnemonic 'OLD CARTS' primarily assist in assessing?
What does the mnemonic 'OLD CARTS' primarily assist in assessing?
Which of the following questions is most relevant when exploring a patient's past history?
Which of the following questions is most relevant when exploring a patient's past history?
Why is it important to ask about drug sensitivities in a patient's history?
Why is it important to ask about drug sensitivities in a patient's history?
During family history taking, what information is of particular interest?
During family history taking, what information is of particular interest?
Which of the following is a typical presentation of allergies?
Which of the following is a typical presentation of allergies?
Which of the following is a factor that belongs to Social and Economic status?
Which of the following is a factor that belongs to Social and Economic status?
When taking a menstrual history, what information is important to gather?
When taking a menstrual history, what information is important to gather?
Which aspect of a patient's obstetric history would include information about forceps-assisted deliveries?
Which aspect of a patient's obstetric history would include information about forceps-assisted deliveries?
What is the primary way a physician gathers information during history taking?
What is the primary way a physician gathers information during history taking?
What is the significance of knowing 'who you are speaking to' before taking a patient's history?
What is the significance of knowing 'who you are speaking to' before taking a patient's history?
In the context of patient interaction, what does 'displaying confidence' entail?
In the context of patient interaction, what does 'displaying confidence' entail?
Which of the following is NOT a typical component of 'personal history' in medical history taking?
Which of the following is NOT a typical component of 'personal history' in medical history taking?
Considering 'special habits' of medical importance, what distinguishes a 'pack-year' in smoking history?
Considering 'special habits' of medical importance, what distinguishes a 'pack-year' in smoking history?
To accurately capture a patient's 'presenting complaint', why is the patient's phrasing prioritized?
To accurately capture a patient's 'presenting complaint', why is the patient's phrasing prioritized?
In the mnemonic 'OLD CARTS,' what does 'L' stand for?
In the mnemonic 'OLD CARTS,' what does 'L' stand for?
What is the primary reason for inquiring about a history of blood transfusions during the 'past history' assessment?
What is the primary reason for inquiring about a history of blood transfusions during the 'past history' assessment?
What is the key reason for documenting known 'drug sensitivities' in a patient's medical record?
What is the key reason for documenting known 'drug sensitivities' in a patient's medical record?
When gathering a 'family history', why is it important to focus on first-degree relatives?
When gathering a 'family history', why is it important to focus on first-degree relatives?
What is the underlying mechanism behind allergic reactions that makes them relevant to medical history?
What is the underlying mechanism behind allergic reactions that makes them relevant to medical history?
How might inquiring about 'over crowding at home' contribute to understanding a patient's health?
How might inquiring about 'over crowding at home' contribute to understanding a patient's health?
In what context would questions about 'Tubectomy or Hysterectomy' be asked during medical history taking?
In what context would questions about 'Tubectomy or Hysterectomy' be asked during medical history taking?
According to Sir William Osler, what fundamental skill should doctors utilize to diagnose patients?
According to Sir William Osler, what fundamental skill should doctors utilize to diagnose patients?
A doctor maintains patient privacy, involve the, in decision making and explains everything they will be doing. What does this mean?
A doctor maintains patient privacy, involve the, in decision making and explains everything they will be doing. What does this mean?
Which of the following would NOT be considered a special habit from a medical standpoint?
Which of the following would NOT be considered a special habit from a medical standpoint?
What is the first step in the diagnostic process?
What is the first step in the diagnostic process?
A patient is allergic to pollen. Which of the following symptoms would they most likely experience?
A patient is allergic to pollen. Which of the following symptoms would they most likely experience?
A doctor starts diagnosing process. Which of the following should be the last step?
A doctor starts diagnosing process. Which of the following should be the last step?
Which of the following is a common allergen?
Which of the following is a common allergen?
Which of the following is the least important when approaching your patient for a true history?
Which of the following is the least important when approaching your patient for a true history?
A first-year medical student is learning to take patient histories, and they consult with the oldest doctor in the hospital. The oldest doctor says "If you listen closely enough, the patient may be telling you the diagnosis. Who shares this sentiment?". What would be the student's MOST accurate response?
A first-year medical student is learning to take patient histories, and they consult with the oldest doctor in the hospital. The oldest doctor says "If you listen closely enough, the patient may be telling you the diagnosis. Who shares this sentiment?". What would be the student's MOST accurate response?
Flashcards
What is history taking?
What is history taking?
A process where information is gained by a physician by asking specific questions to a patient.
Importance of History Taking
Importance of History Taking
An accurate history is critical for determining the etiology of a patient's illness.
How to take history
How to take history
Good communication between patient and doctor; requires practice, patience, concentration, and understanding.
How to greet your patient
How to greet your patient
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Personal History
Personal History
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Special habits
Special habits
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Calculating pack-years
Calculating pack-years
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Presenting Complaint
Presenting Complaint
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History of presenting complaint
History of presenting complaint
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Past history
Past history
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Drug Sensitivities
Drug Sensitivities
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Family History
Family History
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Allergies
Allergies
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Common allergens
Common allergens
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Social and Economic Status
Social and Economic Status
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Menstrual History
Menstrual History
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Obstetric History
Obstetric History
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Study Notes
- History taking is when a physician gains information by asking specific questions to a patient
- Obtaining an accurate history is a critical first step for determining the etiology of a patient's illness
- Diagnosis in medicine depends on clinical history, physical examination, and investigation
How to Take History
- Good communication between patient and doctor is the basis of true history
- Gathering requires practice, patience, concentration, and understanding
- Remember to always listen to the patient, they might be telling you the diagnosis
- The doctor should greet the patient by name
- Make eye contact and display confidence
- Explain everything that will be done and review the plan of care, making sure to involve them in decision making
- Maintaining patient privacy is essential
- Remember to be alert and pay attention
Components of History Taking
- Personal history
- Chief complaint
- History of present illness
- Past history
- Family history
- History of allergies
- Social and economic status
- For female, menstrual and obstetric history
Personal History
- Name
- Age
- Sex
- Occupation
- Marital Status
- Residence
- Special habits
- Special habits include smoking and the consumption of alcohol and drugs
- To calculate a pack-year: multiply the number of packs smoked per day by the number of years the individual has smoked
Presenting Complaint
- Allow the patient to tell his complaints in their own words
- Do not put leading questions to the patient
- Note the current complaints and their duration in a chronological order
History of Presenting Complaint
- Onset
- Nature
- Course
- Associated symptoms
- Duration of each symptom
- Aggravating and relieving factors
- The acronym "OLD CARTS" can be used as a Mnemonic for Symptom Assessment:
- O: Onset - acute or gradual
- L: Location
- D: Duration
- C: Characteristics
- A: Aggravating factors
- R: Relieving factors
- T: Treatments (and response)
- S: Severity
Past History
- Determine if the patient presented with similar complaints in the past
- If present, determine when and how frequently the patient is having these episodes
- History of blood transfusion
- History of operation
- History of any medication
- History of drug sensitivity
- History of travel abroad
- Some people are allergic or sensitive to drugs that are not harmful for most persons
- Some drugs, such as aspirin and penicillin or related antibiotics, may induce allergic reactions and sensitivities in some children
Family History
- Detail of the family history
- Ask if there are any illnesses that run in the family?
- Basic family tree of first-degree relatives
History of Allergies
- Allergies are hypersensitive responses from the immune system to substances that either enter or come into contact with the body
- Common presentations of these Allergies include:
- Cold
- Cough
- Sneezes
- Rashes
- Facial edema
- Common Allergens include:
- Dust
- Mites
- Pollen
- Some kinds of foods
- Drugs
Social and Economic Status
- Inquire about the patient's family lifestyle, daily habits, and diet
- Determine the nature of the patient's work (hard work or sedentary)
- Inquire about the possibility of overcrowding at home, overcrowding aids in the spread of communicable diseases, and the sanitation in and around the house
- Inquire about the presence of pets in the house
Menstrual History
- The following inquiries are relevant:
- Age of menarche
- Duration of each cycle
- Regular or irregular cycles
- Volume of blood loss in each menstrual cycle
- Age of attainment of menopause
- Post-menopausal bleeding
Obstetric History
- Relevant inquiries
- Number of times the patient conceived
- Number of times pregnancy was carried to term
- Number of abortions
- Number of living children, their ages, and the age of the last child delivered
- The time interval between successive pregnancies/abortions
- Mode of delivery (vaginal, forceps assisted, or cesarean)
- Development of oedema legs, hypertension, or seizures in the antenatal or postnatal period
- Gestational diabetes
- Tubectomy or Hysterectomy
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