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Questions and Answers
What is the primary purpose of Step 02 in the history-taking process?
What is the primary purpose of Step 02 in the history-taking process?
- To obtain consent from the patient
- To document the patient's medical treatment plan
- To identify the patient's presenting complaint (correct)
- To gather information about the patient's past medical history
What is the main purpose of reviewing the patient's history at the end of the consultation?
What is the main purpose of reviewing the patient's history at the end of the consultation?
- To ensure the patient's questions are answered
- To provide a summary of the treatment plan
- To confirm the patient's understanding of their condition
- To identify any misunderstandings or errors (correct)
What is the SOCRATES acronym used for in the history-taking process?
What is the SOCRATES acronym used for in the history-taking process?
- To gather information about a patient's family medical history
- To assess a patient's mental state
- To document a patient's medication history
- To guide the questioning for a patient's pain history (correct)
When should a healthcare provider ask a patient for permission to take notes?
When should a healthcare provider ask a patient for permission to take notes?
What is the acronym ICE used for in medical interviewing?
What is the acronym ICE used for in medical interviewing?
What is the primary purpose of Step 04 in the history-taking process?
What is the primary purpose of Step 04 in the history-taking process?
What should you do if a patient asks a question you're unsure about during the consultation?
What should you do if a patient asks a question you're unsure about during the consultation?
What is the primary focus of the main systems to cover during a medical consultation?
What is the primary focus of the main systems to cover during a medical consultation?
Who may be involved in providing a collateral history?
Who may be involved in providing a collateral history?
What is the first step in the history-taking process?
What is the first step in the history-taking process?
What is the purpose of the patient's questions during the consultation?
What is the purpose of the patient's questions during the consultation?
What should you do when you have completed the patient's history and they have asked their questions?
What should you do when you have completed the patient's history and they have asked their questions?
What is the importance of gathering information about a patient's medication history?
What is the importance of gathering information about a patient's medication history?
Why is a patient's family medical history important to document?
Why is a patient's family medical history important to document?
What is the primary goal of taking a patient's medical history during an interview?
What is the primary goal of taking a patient's medical history during an interview?
What type of information is included in a patient's treatment history?
What type of information is included in a patient's treatment history?
What is the purpose of a medical directive?
What is the purpose of a medical directive?
What is included in a patient's medical record?
What is included in a patient's medical record?
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Study Notes
General Framework for Taking History
- Follow a general framework for taking history to gain good marks in history stations
- This framework is also useful for presenting history in a clear and concise manner
Procedure Steps
- Introduce yourself, identify your patient, and gain consent to speak with them
- Ask permission to take notes if needed
- Steps to follow:
- Presenting Complaint (PC)
- History of Presenting Complaint (HPC)
- Past Medical History (PMH)
- Summary of History
- Patient Questions / Feedback
Presenting Complaint (PC)
- Identify the patient's main complaint (e.g., chest pain)
History of Presenting Complaint (HPC)
- Gain detailed information about the complaint using the SOCRATES acronym
- SOCRATES stands for:
- Site: Where exactly is the pain?
- Onset: When did it start, was it constant/intermittent, gradual/ sudden?
- Character: What is the pain like (e.g., sharp, burning, tight)?
- Radiation: Does it radiate/move anywhere?
- Associations: Is there anything else associated with the pain (e.g., sweating, vomiting)?
- Time course: Does it follow any time pattern, how long did it last?
- Exacerbating / relieving factors: Does anything make it better or worse?
- Severity: How severe is the pain (consider using the 1-10 scale)?
Past Medical History (PMH)
- Gather information about a patient's other medical problems (if any)
- Cover the main systems:
- CVS
- Respiratory
- GI
- Neurology
- Genitourinary/renal
- Musculoskeletal
- Psychiatry
Summary of History
- Review the patient's history and repeat back important points
- Use the ICE acronym to address:
- Ideas: What the patient thinks is wrong with them
- Concerns: What the patient is worried about
- Expectations: What the patient hopes to achieve from the consultation
Patient Questions / Feedback
- Answer patient questions or provide information when possible
- If unsure, say you will ask seniors or provide further information later
Family History
- A patient's family medical history can play a significant role in their health
- Document genetic health concerns, hereditary diseases, and cancers
Treatment History
- A patient's treatment history is a vital part of their medical record
- Include:
- Chief complaints
- History of illness
- Vital signs
- Physical examination
- Surgical history
- Obstetric history
- Medical allergies
- Family history
- Immunization history
- Habits (e.g., diet, alcohol intake, exercise, drug use/abuse, smoking)
Medical Directives
- Medical directives outline patient directions for medical care if they cannot communicate
- Include:
- DNR (Do Not Resuscitate order)
- Will and other medical directives
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