Medical History Taking and Pain Assessment

History Taking

• History taking is a crucial part of medical practice.
• Key components include medical history, case history, and anamnesis.
• Symptoms, clinical signs, differential diagnosis, and history and physical are also integral parts.
• Initial steps involve introducing oneself carefully and identifying the patient.
• Patient identification involves key details like date of birth, sex, and ethnicity.
• Example patient details include: date of birth: June 18, 1978, sex: Male, ethnicity: Black American.
• Presenting complaints are essential.
• An example patient's chief complaints: biliary colic pain, sweating, yellow skin.
• The presenting complaint includes pain, location, quality, severity, timing, context, and modifying/relieving factors.

Pain Assessment

• Assess pain using the "SOCRATES" rule.
• Factors include site, onset, character, radiating pain, associated symptoms, timing, exacerbating/relieving factors, and severity.
• A pain assessment model uses site, onset, character, radiation, associated symptoms, time/duration, exacerbating/relieving factors, and severity.
• A universal pain assessment tool uses a 0-10 scale for patient self-assessment.
• Use faces or behavioral observations to interpret expressed pain when the person can't communicate.

Past Medical and Surgical History

• Important to gather past medical and surgical history.
• Gathering details, for example, symptoms, allergies, medications, pertinent medical history, last meal, etc.

Social History

• Number of pack-years is calculated as packs smoked per day multiplied by years as a smoker.
• Alcoholic drinks use ABV (alcohol by volume) to measure pure alcohol amount.
• One unit of alcohol has various examples, like half a pint of beer, half a small glass of wine, etc.
• Classification of alcohol consumption includes frequent excessive drinkers, occasional excessive drinkers, moderate drinkers, and abstainers.

Summary of History

• Example patient: James Taylor, age 55, height 5'8", weight 170 lbs.
• Chief complaints include biliary colic pain (pain scale 9), sweating, chills, yellow skin and eyes, and a body temperature of 39.8°C
• Past medical history, allergies and drug reactions, current medications, and past hospitalizations are also recorded.
• Includes pertinent information like tobacco/alcohol use, family status, and occupation.

Patient Feedback, Ending, and Inhibiting Factors

• After reviewing patient history, feedback from the patient is important.
• Important points from each conversation should be repeated back to the patient.
• Inhibiting factors and concerns should be clearly understood when ending.

This quiz covers the essential components of history taking in medical practice, including key patient details and presenting complaints. Additionally, it focuses on pain assessment using the SOCRATES model, which helps in evaluating pain characteristics and severity. Test your knowledge on these crucial aspects of medical history and pain evaluation.