Patient Consultation Techniques
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Questions and Answers

What is the first step in initiating a session with a patient?

  • Ask the patient about their diagnosis
  • Introduce yourself and your role (correct)
  • Immediately start asking medical history questions
  • Present the treatment options

    • Which technique is important in gathering information about a patient's complaints?

  • Using only closed questions
  • Avoiding open-ended questions
  • Directing the patient to focus on specific details
  • Listening attentively without interrupting (correct)

    • What does the 'C' in the SOCRATES acronym stand for when gathering information about pain?

  • Complication
  • Cause
  • Character (correct)
  • Consistency

    • What is the purpose of agenda setting in a patient consultation?

    <p>To balance both the patient's and the clinician's needs</p> Signup and view all the answers

    Which type of question is an example of an open question?

    <p>Can you describe your cough?</p> Signup and view all the answers

    What is a key factor to consider when understanding a patient's expectations?

    <p>How the problem affects their daily living</p> Signup and view all the answers

    When assessing joint pain using the SOCRATES framework, what does 'A' stand for?

    <p>Associated symptoms</p> Signup and view all the answers

    Which of the following is an example of a closed question?

    <p>Does your pain improve with rest?</p> Signup and view all the answers

    Which aspect is NOT part of the Calgary Cambridge Consultation Model?

    <p>Explaining complex medical terminology</p> Signup and view all the answers

    What is one aspect you should confirm with the patient after listening to their opening statement?

    <p>The exact nature of their complaint</p> Signup and view all the answers

    What is a critical component of effective communication according to the Calgary Cambridge model?

    <p>Maintaining eye contact and using empathetic language</p> Signup and view all the answers

    What comes immediately after the 'Introduction and Consent' phase in history taking?

    <p>Presenting Complaint</p> Signup and view all the answers

    What should a clinician do when transitioning to a new section of the consultation?

    <p>Summarize regularly before moving to the next section</p> Signup and view all the answers

    Which behavior is essential in building rapport with patients?

    <p>Acknowledging patient views and providing support</p> Signup and view all the answers

    How should a clinician involve the patient during the consultation?

    <p>By asking for their thoughts on proposed ideas</p> Signup and view all the answers

    What is the purpose of the Systems Review in the history taking sequence?

    <p>To gather additional relevant medical information</p> Signup and view all the answers

    What does the 'C' in SOCRATES for joint pain represent?

    <p>Character</p> Signup and view all the answers

    In the context of cough assessment, what does the 'E' in SOCRATES refer to?

    <p>Exacerbating factors</p> Signup and view all the answers

    What is being assessed with the 'R' in SOCRATES when gathering information about symptoms?

    <p>Radiation</p> Signup and view all the answers

    Which of the following options would be considered an 'A' in the SOCRATES approach for joint symptoms?

    <p>Associated symptoms</p> Signup and view all the answers

    To effectively assess the severity of a symptom, which aspect is crucial according to the SOCRATES method?

    <p>Severity</p> Signup and view all the answers

    Which question is most relevant for gathering past medical history?

    <p>Do you have any known medical conditions?</p> Signup and view all the answers

    What type of questions should be used to assess current medications according to the provided framework?

    <p>Open Questions</p> Signup and view all the answers

    Which of the following is NOT an example of exacerbating factors in cough assessment?

    <p>Daily routine</p> Signup and view all the answers

    What is the first step to initiate a consultation with a patient?

    <p>Introduce yourself and show respect.</p> Signup and view all the answers

    Which type of question encourages a patient to give detailed information?

    <p>Open question</p> Signup and view all the answers

    What should a doctor do to confirm the patient's problems during the consultation?

    <p>Check with the patient to confirm the problem(s).</p> Signup and view all the answers

    What is the purpose of summarizing during a patient interaction?

    <p>To ensure correct interpretation and demonstrate attentive listening.</p> Signup and view all the answers

    Which communication technique helps the healthcare professional gather specific information about the patient's symptoms?

    <p>Asking open and closed questions.</p> Signup and view all the answers

    Why is it important to listen attentively during a patient's opening statement?

    <p>To understand their main concerns without interruption.</p> Signup and view all the answers

    What should the doctor aim to establish regarding dates during a patient consultation?

    <p>A chronological sequence of symptom occurrences.</p> Signup and view all the answers

    When discussing a patient's ideas, concerns, and expectations, which aspect is primarily focused on?

    <p>The patient's beliefs about the cause of their problem.</p> Signup and view all the answers

    What is a key distinction between a mild reaction and anaphylaxis?

    <p>Anaphylaxis can lead to collapse and rash.</p> Signup and view all the answers

    Which of the following is included in smoking history?

    <p>Quantity of cigarettes and duration of smoking.</p> Signup and view all the answers

    What is one of the Calgary Cambridge Consultation Model's key aspects?

    <p>Understanding the patient's ideas and concerns.</p> Signup and view all the answers

    How many alcohol units is equivalent to one pint of beer?

    <p>2 units</p> Signup and view all the answers

    What is included in the social history section of a patient assessment?

    <p>Details about living arrangements and support systems.</p> Signup and view all the answers

    What is the ideal number of students in a small group tutorial?

    <p>10-12 students</p> Signup and view all the answers

    Which chronic condition is commonly noted to run in families?

    <p>Diabetes</p> Signup and view all the answers

    What is the purpose of summarizing findings in a consultation?

    <p>To ensure patient understanding and participation.</p> Signup and view all the answers

    What is the first step in the Calgary Cambridge Consultation Model when starting a session with a patient?

    <p>Greet the patient and ask their name</p> Signup and view all the answers

    Which aspect does the Calgary Cambridge model emphasize as crucial during the consultation process?

    <p>Understanding the patient's ideas, concerns, and expectations</p> Signup and view all the answers

    What should be included in the summary of findings during a consultation according to the Calgary Cambridge model?

    <p>Forming a differential diagnosis and management plan</p> Signup and view all the answers

    The Calgary Cambridge Consultation Model was developed by which of the following pairs?

    <p>Suzanne Kurtz and Jonathan Silverman</p> Signup and view all the answers

    In the context of the Calgary Cambridge Consultation Model, establishing rapport is primarily related to which of the following actions?

    <p>Introducing oneself and explaining your role</p> Signup and view all the answers

    What is the main purpose of the 'History of Presenting Complaint' section in the history taking sequence?

    <p>To understand the current issue that prompted the patient visit</p> Signup and view all the answers

    Which of the following is essential for building rapport with a patient during a consultation?

    <p>Demonstrating empathy and acknowledging patient views</p> Signup and view all the answers

    Sign-posting during a consultation is primarily used for which purpose?

    <p>To guide the patient through different sections of the consultation</p> Signup and view all the answers

    In the Calgary Cambridge Consultation Model, which aspect is vital for effective communication?

    <p>Paying attention to non-verbal behaviors such as eye contact</p> Signup and view all the answers

    What should a clinician do during the summary phase of a consultation?

    <p>Recap the key points discussed and confirm understanding</p> Signup and view all the answers

    Which element is NOT a part of the history taking sequence?

    <p>Physical Examination</p> Signup and view all the answers

    How can a clinician effectively involve the patient during the consultation?

    <p>By asking for their thoughts on the proposed management</p> Signup and view all the answers

    Which statement best reflects the aims of the Systems Review in the history taking process?

    <p>To provide a comprehensive overview of the patient's health across different systems</p> Signup and view all the answers

    What is an appropriate way to start a consultation with a patient?

    <p>Inquire if the patient is comfortable and gain consent to proceed.</p> Signup and view all the answers

    How can a clinician effectively summarize a patient's opening statement?

    <p>By paraphrasing and clarifying the main points.</p> Signup and view all the answers

    What is the primary goal of agenda setting in a patient consultation?

    <p>To negotiate an agenda that respects both the patient's and clinician's needs.</p> Signup and view all the answers

    Which technique is best for exploring a patient's problems during the consultation?

    <p>Encouraging the patient to share their story using open questions.</p> Signup and view all the answers

    What is a key element to consider when addressing a patient's concerns?

    <p>Listening actively and validating their worries.</p> Signup and view all the answers

    What should a clinician do if a patient's expression or body language indicates confusion?

    <p>Ask if the patient needs clarification on anything.</p> Signup and view all the answers

    Which approach should be taken when clarifying patient statements?

    <p>Request the patient to explain their statement in more detail.</p> Signup and view all the answers

    Which of the following techniques enhances the reliability of patient information during consultations?

    <p>Establishing a sequence of events regarding symptoms.</p> Signup and view all the answers

    Which of the following best describes the Calgary Cambridge Model in communication?

    <p>A model emphasizing patient engagement and communication during consultations.</p> Signup and view all the answers

    What is a critical aspect of personal and professional identity in healthcare?

    <p>Applying professionalism, leadership, and resilience.</p> Signup and view all the answers

    What do social determinants of health refer to?

    <p>Factors that impact health beyond direct medical care.</p> Signup and view all the answers

    How can teams improve patient care according to effective strategies in healthcare?

    <p>Through strong communication, collaboration, and interventions.</p> Signup and view all the answers

    Which of the following describes the fundamental principles of pharmacology?

    <p>The principles governing drug actions and interactions in the body.</p> Signup and view all the answers

    What is an important outcome of understanding morbidity and mortality trends?

    <p>To inform public health policies and resource allocation.</p> Signup and view all the answers

    In the context of microbiological infections, what is the significance of identifying medically important microorganisms?

    <p>It aids in understanding and managing infectious diseases.</p> Signup and view all the answers

    What role does effective communication play in consultations according to the learning outcomes?

    <p>It is essential for building rapport and understanding patient needs.</p> Signup and view all the answers

    Which factor is examined in the 'E' category of SOCRATES for assessing joint pain?

    <p>Factors that worsen the pain</p> Signup and view all the answers

    What does the 'S' in SOCRATES for cough assessment encompass?

    <p>Severity of symptoms</p> Signup and view all the answers

    In the context of gathering past medical history, what type of questions would be considered closed questions?

    <p>Have you experienced any heart problems?</p> Signup and view all the answers

    When evaluating associated symptoms in the SOCRATES framework, what does 'A' specifically refer to?

    <p>Activities impacted</p> Signup and view all the answers

    Which question would be most useful when assessing the onset of joint pain?

    <p>When did the pain start?</p> Signup and view all the answers

    What type of factors related to cough assessment are addressed by the 'R' in SOCRATES?

    <p>Radiation to other parts of the body</p> Signup and view all the answers

    When considering medications in a patient's history, which aspect is NOT typically relevant?

    <p>Patient's occupation</p> Signup and view all the answers

    What does the 'C' in SOCRATES for joint pain assessment illustrate?

    <p>Character of the pain experienced</p> Signup and view all the answers

    What is a crucial aspect of gaining consent during a patient consultation?

    <p>Clearly explaining the purpose of each question</p> Signup and view all the answers

    What should be avoided when gathering information about a patient's presenting complaint?

    <p>Interrupting the patient for clarification</p> Signup and view all the answers

    In the SOCRATES framework for chest pain, what does the 'R' specifically assess?

    <p>If the pain radiates to other areas</p> Signup and view all the answers

    During the exploration of the patient's problem, what is the recommended way to encourage a narrative?

    <p>Using open-ended questions</p> Signup and view all the answers

    What does the 'E' in the SOCRATES acronym refer to when assessing symptoms?

    <p>Exacerbating factors and relieving factors</p> Signup and view all the answers

    In the context of gathering information, how should the 'S' in SOCRATES for joint pain be assessed?

    <p>By identifying the site of pain</p> Signup and view all the answers

    What is the goal of 'agenda setting' during a consultation?

    <p>To address both the patient’s and clinician’s needs</p> Signup and view all the answers

    Which questioning technique is especially beneficial for exploring a patient's cough symptoms?

    <p>Employing a mix of open and closed questioning</p> Signup and view all the answers

    What is the primary goal of negotiating an agenda with a patient during a consultation?

    <p>To consider both the patient's and clinician's needs</p> Signup and view all the answers

    Which questioning technique is most effective for encouraging detailed patient responses?

    <p>Open questions</p> Signup and view all the answers

    How should a clinician respond if a patient's explanation is unclear?

    <p>Ask the patient to explain in more detail</p> Signup and view all the answers

    During the session, which of the following is NOT an essential component of effective communication?

    <p>Utilizing medical jargon for clarity</p> Signup and view all the answers

    When picking up on cues during a consultation, what is the clinician primarily observing?

    <p>The patient’s expressions and body language</p> Signup and view all the answers

    What should a clinician summarize after listening to a patient's opening statement?

    <p>The interpretation of the patient's concerns</p> Signup and view all the answers

    While exploring a patient's problems, what is a crucial aspect to clarify?

    <p>The specific dates when symptoms began</p> Signup and view all the answers

    Why is it important to consider a patient's ideas, concerns, and expectations during a consultation?

    <p>To enhance diagnostic accuracy and provide empathetic care</p> Signup and view all the answers

    What is a primary focus of the Calgary Cambridge Consultation Model when engaging with a patient?

    <p>Building a relationship through empathy and support</p> Signup and view all the answers

    During a consultation, how should a clinician effectively transition between different sections?

    <p>Use sign-posting to clearly indicate the shift to the next topic.</p> Signup and view all the answers

    What is included in the 'Social History' during the history taking sequence?

    <p>The patient's occupational and lifestyle factors</p> Signup and view all the answers

    Which communication technique is most effective in involving patients in the consultation process?

    <p>Asking the patient for their thoughts on proposed ideas</p> Signup and view all the answers

    What aspect of non-verbal communication is crucial for building rapport with patients?

    <p>Employing an approachable tone and confident body language</p> Signup and view all the answers

    In the context of patient consultations, which phase comes after gathering the history of the present complaint?

    <p>Past Medical History</p> Signup and view all the answers

    What role does summarizing play in the consultation process?

    <p>It provides an opportunity to clarify and confirm information with the patient.</p> Signup and view all the answers

    Which of the following best describes the purpose of the 'Differential Diagnosis' stage in history taking?

    <p>To explore and evaluate potential conditions based on gathered information</p> Signup and view all the answers

    What is the maximum number of alcohol units recommended per week for males?

    <p>17 units</p> Signup and view all the answers

    Which of the following best describes common symptoms of anaphylaxis?

    <p>Collapse and severe respiratory distress</p> Signup and view all the answers

    Which family medical condition is regularly noted to have a genetic predisposition?

    <p>Diabetes</p> Signup and view all the answers

    What is the primary purpose of documenting social history during a patient consultation?

    <p>To assess the patient's needs and lifestyle.</p> Signup and view all the answers

    In the Calgary Cambridge Consultation Model, what is emphasized during the initial stages of a consultation?

    <p>Building rapport and understanding patient expectations</p> Signup and view all the answers

    How is a pack year defined in smoking history assessment?

    <p>20 cigarettes consumed for one year</p> Signup and view all the answers

    What is the role of summarizing findings in a patient consultation?

    <p>To ensure clarity and reinforce the patient's understanding</p> Signup and view all the answers

    Which of the following best reflects the main purpose of small group tutorials in medical education?

    <p>To enhance communication skills through peer interaction</p> Signup and view all the answers

    When assessing cough severity, which factor should NOT be considered?

    <p>Presence of visual symptoms</p> Signup and view all the answers

    In the SOCRATES framework for joint pain assessment, which factor is primarily concerned with understanding when the pain began?

    <p>Onset</p> Signup and view all the answers

    Which of the following symptoms would NOT be included when assessing associated symptoms in joint pain?

    <p>Visual disturbances</p> Signup and view all the answers

    Which of the following best describes 'exacerbating factors' in cough assessment?

    <p>Factors that make the cough worse</p> Signup and view all the answers

    What aspect of the SOCRATES framework assesses pain intensity on a scale from 1 to 10?

    <p>Severity</p> Signup and view all the answers

    In gathering information about past medical history, which question type is ideal for assessing the presence of specific conditions?

    <p>Closed questions</p> Signup and view all the answers

    Which option represents a possible allergic reaction to a substance?

    <p>Itching and rash</p> Signup and view all the answers

    Which timing aspect of symptoms is NOT typically addressed in the SOCRATES framework?

    <p>What medications have been taken recently?</p> Signup and view all the answers

    Study Notes

    Initiating the Session

    • Greet the patient and introduce yourself
    • Ensure the patient is seated comfortably
    • Show interest and respect
    • Gain consent to proceed with the consultation

    Identifying the Reason for Consultation

    • Ask the patient why they are there today.
    • Listen attentively to the patient’s response without interrupting.
    • Check with the patient to confirm the reason for their visit.
    • Set an agenda, considering both the patient’s and your own needs.

    Gathering Information: Exploration of Problems

    • Encourage the patient to tell the story of their problem(s).
    • Use open and closed questioning techniques.
    • Open questions encourage detailed responses.
    • Closed questions elicit yes/no answers.
    • Listen attentively to the patient’s responses, both verbally and non-verbally.

    Gathering Information: Picking up on Cues

    • Pay attention to the patient’s cues, expressions, and body language.
    • Use appropriate language, avoiding medical jargon.
    • Establish dates and sequence of events.
    • Clarify if unclear information is provided.
    • Summarise key findings, confirming your understanding and demonstrating attentiveness.

    Identifying Ideas, Concerns, and Expectations

    • Be aware of the patient’s:
      • Ideas: Beliefs about the cause of their problem.
      • Concerns: Worries about their symptoms.
      • Expectations: What kind of help they expect.
    • Consider how the problem is affecting the patient’s life and daily living.

    Providing Structure to the Consultation

    • Ensure consultation flow with a logical structure and sequence.
    • Summarise regularly before moving to the next section.
    • Use signposting phrases, like "Now, I'd like to ask about your past medical history."

    Building a Relationship with the Patient

    • Pay attention to non-verbal behavior, including:
      • Eye contact
      • Facial expressions
      • Tone
      • Volume
      • Rate of speech
      • Posture
      • Position
      • Movement
    • Reduce barriers, e.g., minimize computer use during the interview.
    • Develop rapport through empathy, acknowledging patient views and providing support.
    • Involve the patient, e.g., “Based on what we’ve discussed, my thoughts are… what do you think about that?”

    History Taking Sequence

    • Introduction and Consent
    • Presenting Complaint
    • History of Presenting Complaint
    • Past Medical History
    • Past Surgical History
    • Medications
    • Allergies
    • Social History
    • Family History
    • Systems Review
    • Summary
    • Differential Diagnosis
    • Management Plan

    Past Medical History

    • Use open questions to gain information about:
      • General health
      • Known medical conditions
      • Current or previous medical care
      • Past surgeries
      • Previous musculoskeletal, cardiac, respiratory, or gastrointestinal problems
    • Use closed questions to confirm the presence of specific conditions.

    Medications

    • Identify current medications, including prescription, over-the-counter (OTC), and herbal remedies.
    • Consider any recreational drug use relevant to the consultation.
    • Document medications, including:
      • Name
      • Dosage
      • Frequency
      • Length of use
      • Reason for taking
      • Compliance
      • Side effects

    Allergies

    • Record any known allergies, including:
      • Medications
      • Latex
    • Document the severity of the allergy and the reaction experienced.
      • Mild reaction vs. anaphylaxis

    Social History

    • Gather information about:
      • Home life
      • Living arrangements
      • Support network
      • Occupation
      • Stress level
      • Hobbies
      • Exercise habits

    Social History (Continued)

    • Assess the patient’s:
      • Smoking History:
        • Are they a current or former smoker?
        • How much did they smoke?
        • For how long?
      • Alcohol History:
        • Do they drink alcohol?
        • How often?
        • How much do they drink per occasion?

    Family History

    • Document the health history of:
      • Parents
      • Siblings
      • Include chronic conditions and their status (living or deceased).
    • Assess for a family history of any known conditions, including:
      • Cystic fibrosis
      • Haemochromatosis
      • Diabetes
      • Heart disease
      • Stroke
      • Hypertension

    Beyond the Scope of Year 1

    • The following components of history taking usually fall outside the scope of the first year of medical training but may be covered in later years:
      • Systems Review
      • Summary
      • Differential Diagnosis
      • Management Plan

    Small Group Tutorials

    • Review lecture materials and relevant notes before a tutorial.
    • A GP tutor will facilitate the session.
    • Expect 10-12 students per tutorial.
    • Students will form groups of three (patient, doctor, observer).

    Learning Outcomes

    • Demonstrate understanding of communication skills within a consultation setting.
    • Be familiar with the Calgary Cambridge Consultation Model.
    • Described the first four headings of the Calgary Cambridge Consultation Model.
    • Understand the structure of history taking and its relationship to the consultation model.
    • Be aware of summarising findings, forming a differential diagnosis, and developing a management plan.
    • Recognize the importance of addressing the patient’s ideas, concerns, and expectations during the consultation.

    Calgary Cambridge Consultation Model

    • Developed by Suzanne Kurtz and Jonathan Silverman in 1996
    • Revised over time, based on research
    • Many other consultation models exist, each aiming to structure the patient interaction
    • It is helpful for students starting out seeing patients

    Calgary Cambridge Consultation Model

    • This model encourages the doctor to be aware of the patient's ideas, concerns, and expectations (ICE)
    • It is valuable for creating a good relationship, listening to the patient, and understanding their perspective

    Initiating the Session

    • Greet the patient, ask their name
    • Introduce yourself and explain your role
    • Ensure the patient is comfortable
    • Demonstrate respect and interest
    • Gain consent from the patient before beginning the session

    Identify the Reason(s) for the Consultation

    • Use an open question to identify the main reason for the consultation
    • Listen attentively to the patient's initial statement, without interrupting or directing their response
    • Check if you understand the problem correctly
    • Negotiate an agenda with the patient, addressing both their needs and your own, to focus the consultation

    Gathering Information

    • Use a structured approach to explore the patient's problems
    • Encourage the patient to tell their story
    • Use open and closed questions to gather information
    • Pick up on verbal and non-verbal cues
    • Use clear and appropriate language, avoiding jargon
    • Establish a timeline of events and clarify anything that is unclear
    • Regularly summarise information back to the patient to ensure accuracy and show attentiveness

    SOCRATES

    • Useful to systematically gather information about symptoms
    • Stands for Site, Onset, Character, Radiation, Associated symptoms, Timing, Exacerbating factors, Relieving factors, Severity
    • Should be used for the presenting complaint and any other patient-reported symptoms

    Past History

    • Divided into Medical History, Surgical History, Medications, Allergies, Social History and Family History
    • The aim is to learn about past experiences

    Past History: Medical History

    • Open questions:
      • Focus on their overall health
      • Ask if they have any known medical conditions
      • Enquire if they have any regular visits with a doctor or clinic
    • Closed questions:
      • Aim to cover specific conditions, such as those related to the presenting complaint
      • Helpful to prompt the patient if they have forgotten about a history
      • If the patient reports having such conditions, be sure to explore the details

    Past History: Surgical History

    • Open questions:
      • Explore if they have had any previous operations
      • Ask about any investigations done in a hospital setting
    • Specific to the presenting complaint:
      • Ask about previous musculoskeletal, cardiac, respiratory, gastrointestinal problems
      • Ask about any other relevant procedures they have had

    Medications

    • Current medications prescribed
    • OTC medications
    • Herbal remedies
    • Recreational drug use (relevant to the consultation)
    • Record what the medication is for, when it was prescribed, and if the patient is compliant with the medication
    • Ask if the patient tolerates the medication or experiences any side effects
    • Ensure there are no interactions between medications

    Allergies

    • Any allergies to medication or latex (especially if the patient is undergoing an examination)
    • Explore the extent of the allergy, including what happened when exposed
    • Record specific details of the reaction

    Social History

    • Explore factors related to the presenting complaint, like lifestyle or environment relevant to their health
    • For example, if the patient complains of back pain, enquire about their job.
    • If the patient presents with chest pain, ask about smoking and alcohol consumption

    Family History

    • Explore the patient’s family history to identify any relevant conditions, either by asking about specific diseases or using a family tree with an outline of those diagnosed
    • It is best practice to ask about parents, grandparents, siblings, children, and other close relatives

    Systems Review

    • Ask about other systems that may be related to the presenting complaint
    • Example: if the patient has chest pain, review the cardiovascular system (including shortness of breath, palpitations, chest pain, leg swelling) and respiratory system (cough, sputum, wheezing)
    • Ask simple open questions regarding each system, and use closed questions to clarify

    Summary

    • Before moving onto the next section, summarise the information collected using the patient’s own words
    • For example, “So, the chest pain that brought you here started yesterday, is worse when you breathe in deeply, and eases when you take ibuprofen.”
    • This also demonstrates that you have been listening to the patient’s story

    Differential Diagnosis

    • Form a list of possible conditions that could be causing the patient’s symptoms
    • This should be based on your interpretation of the history and examination
    • Use the information gathered to rule out or support certain possibilities

    Management Plan

    • Create a plan of action for treating the patient, based on your assessment and diagnosis
    • This may include investigations, treatment, or further consultation
    • The final plan should be discussed and agreed upon by both patient and the doctor
    • Greet the patient, ask their name
    • Introduce yourself and say what you do
    • Make sure the patient is seated comfortably
    • Show interest and respect
    • Gain consent to proceed

    Initiating the Session

    • Identify the reason(s) for the patient’s consult
    • Listen to the patient’s opening statement without interrupting
    • Check with the patient to confirm the problem(s)
    • Negotiate an agenda with the patient

    History of Presenting Complaint

    • Encourage the patient to tell the story of the problem(s)
    • Use open and closed questioning techniques
    • Listen attentively to facilitate the patient's responses verbally and non-verbally
    • Pick up on cues, expressions, and body language

    Gathering Information for Pain

    • Use SOCRATES for pain:
      • Site: Where is the pain?
      • Onset: When did the pain start? Was it sudden or gradual?
      • Character: What does the pain feel like? (e.g., dull, sharp, throbbing, burning)
      • Radiation: Does the pain radiate anywhere?
      • Associated symptoms: Are there any other symptoms present?
      • Timing: How long does the pain last?
      • Exacerbating/Relieving factors: What makes the pain worse? What makes it better?
      • Severity: On a scale of 1-10, how severe is the pain? What impact does it have on daily activities?

    Past Medical History

    • Open questions:
      • How is your health generally?
      • Do you have any known medical conditions?
      • Are you attending a doctor or clinic regularly?
    • Closed questions:
      • Do you have asthma? High blood pressure? High cholesterol? Diabetes? Depression? Epilepsy?
      • Rheumatic fever or heart disease? Stroke?

    Past Surgical History

    • Have you had any previous operations or investigations done in hospital?

    Medications

    • Current medications: Prescribed, over the counter (OTC), herbal remedies, recreational drug use
    • List of medication:
      • What are they for?
      • When prescribed?
      • Compliance?
      • Tolerated/side effects?

    Allergies

    • Any known allergies to medications or latex
    • Extent of allergy:
      • What happened when exposed? (e.g., nausea/vomiting/rash/swelling/collapse/hospitalisation)
      • Mild reaction vs anaphylaxis

    Social History

    • Home:
      • Who do you live with?
      • Do you have any dependents/children?
      • Do you have good support from family and friends/neighbors?
    • Occupation:
      • Stressful?
      • Sedentary?
      • How do you manage work/life balance?
    • Hobbies:
      • Sport?
      • How much exercise per week?
      • Other hobbies?

    Social History (Continued)

    • Smoking History:
      • Do you smoke?
      • Have you ever smoked?
      • How many?
      • For how long?
      • One pack year = 20 cigarettes/day/year
    • Alcohol History:
      • Do you drink alcohol?
      • Would you drink every day?
      • How much?
      • How often?
      • Glass of beer - 1 unit
      • Pint of beer - 2 units
      • Glass of wine - 1-2 units
      • 1 measure of spirits - 1 unit

    Family History

    • Parents/Siblings:
      • Living or deceased?
      • Chronic conditions?
    • Any known conditions that run in the family? (e.g., cystic fibrosis, haemochromatosis)
    • Any conditions that can occur frequently in families? (e.g., diabetes, heart disease, stroke, or high blood pressure?)

    Beyond the Scope of Year 1

    • Systems Review
    • Summary of findings
    • Differential Diagnosis
    • Management Plan

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    FFP1 Introduction to Communication and History Taking PDF

    Description

    This quiz covers essential techniques for initiating and conducting a patient consultation. You will learn how to greet patients, identify their reasons for visiting, and gather comprehensive information through effective questioning and active listening. Mastering these skills is crucial for building rapport and ensuring a successful consultation.

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