ECPD History Taking PDF

‫د‪.‬اﻧﻌﺎم ﻣﺟﯾد ﺣﺳون‬ ‫ﺑورد ﻋرﺑﻲ ﻧﺳﺎﺋﯾﺔ ووﻻدة؛ ﻋﺿوة وزﻣﯾﻠﺔ اﻟﻛﻠﯾﺔ اﻟﻣﻠﻛﯾﺔ )ﻟﻧدن(‬ ‫دﺑﻠوم اﻟﺟراﺣﺔ اﻟﻧﺎظورﯾﺔ‬ ‫ﺟﺎﻣﻌﺔ اّﺷور‬ What is ECPD?  What is History taking? It is a process by which information is gained by a physician by asking specific...

‫د‪.‬اﻧﻌﺎم ﻣﺟﯾد ﺣﺳون‬ ‫ﺑورد ﻋرﺑﻲ ﻧﺳﺎﺋﯾﺔ ووﻻدة؛ ﻋﺿوة وزﻣﯾﻠﺔ اﻟﻛﻠﯾﺔ اﻟﻣﻠﻛﯾﺔ )ﻟﻧدن(‬ ‫دﺑﻠوم اﻟﺟراﺣﺔ اﻟﻧﺎظورﯾﺔ‬ ‫ﺟﺎﻣﻌﺔ اّﺷور‬ What is ECPD?  What is History taking? It is a process by which information is gained by a physician by asking specific questions to the patient with the aim of obtaining information useful in formulating a diagnosis and providing medical care to the patient  Importance of History Taking? Diagnosis in medicine is based on o Clinical history o Physical Examination o Investigations Obtaining an accurate history is the critical first step in determining the etiology of a patient's illness A large percentage of the time (70 70%%), you will actually be able make a diagnosis based on the history alone  How to take a history ? The basis of a true history is good communication between doctor and patient It takes practice, patience, understanding and concentration "Always listen to the patient they might be telling you the diagnosis” (Sir William Osler 1849-1919) Approach to history taking Approach to history taking  Approach to history taking Ø Be alert and play full attention  Approach to history taking Ensure consent has been gained Maintain privacy and dignity Ensure the patient is as comfortable as possible Summaries each stage of the history taking process Involve the patient in the history taking process if in a bad mood or distracted during the consultation, you can end up “making making a history rather than taking a history".  Components of History taking 1. Patient's profile 2. Chief complaint 3. History of the present illness 4. Past medical history 5. Family history 6. Socioeconomic history 7. System Review  1. Patients profile Date and Time Name Age Sex Religion Marital status Occupation Address Who gave the history?  2. Chief complaint The main reason for which the patient is trying to seek medical help by visiting the physician Usually a single symptoms, occasionally more than one complaints eg: fever, headache, pain… etc. The patient describe the problem in their own words It should be recorded in patients own words The complaint should be recorded with their onset duration  2. Chief complaint…Cont. How to ask for chief complaint? o What brings you here? o How can I help you? o What seems to be the problem? If there is more than one complaint, it should be written according to chronological order  2. Chief complaint…Cont. Example: Fever-2 weeks, Productive cough-1 week, Vomiting -2 days, Fatigue-1day,  3. History of the present illness Elaborate on the chief complaint in detail Ask relevant associated symptoms Gain as much information you can about the specific complaint Lead the conversation by asking questions. Always start with an open ended question and take the time to listen to the patient's 'story'. Once the patient has completed their narrative then closed questions can be asked to clarify. Leading question are to be avoided 3. History of the present illness…Cont. Open questions allow patients to express their own thoughts and feelings, e.g.: o “What was the first thing you noticed wrong when you became ill?” o “Is there anything else that you want to mention?” Closed questions are requests for factual information, e.g: o “When did this pain start?” o “Have you ever coughed up any blood?” Leading questions are based on your own assumptions that lead the patient to the answer you want to hear. e.g: o “You do not miss any doses of your medication, do you?” 3. History of the present illness…Cont. For details of present problem ask about and narrate in details: o Time of onset/ mode of evolution/ any investigation; treatment & outcome/any associated +'ve or -'ve symptoms o Avoid medical terminology and make use of a descriptive language that is familiar to patients o Sequential presentation o Always relay story in days before admission  3. History of the present illness…Cont. Tips to gather information about characteristics of pain (SOCRATES): S: Site O: Onset C: Character R: Radiation (of pain or discomfort) A: Associated symptoms T: Timing(duration, course, pattern) Socrates was a Greek E: Exacerbating & relieving factors philosopher from Athens S: Severity 3. History of the present illness…Cont. Case scenario #1: Trauma with infected wound The patient was apparently well 1 week before the admission when the patient fell while gardening and cut his foot with a stone. By that evening, the foot became swollen and patient was unable to walk. Next day patient attended a private clinic where they gave him some oral medicines. The patient doesn't know the name of the medicines given but says that he was told the medicine would suppress his leg pains. However, there was no improvement in his condition. Two days prior to admission in hospital, the swelling in the foot started to discharge pus. There is high fever and rigors with nausea and vomiting. Case scenario # 2: Leg Pain in a 62-yr-old Man A 62-yr-old man comes to the emergency department in December because he has had 2 days of progressively worsening pain in his right lower leg between the knee and ankle. He says that several hours before arrival in the emergency department, he began to feel generally ill and aching all over. He thought he had a fever but did not take his temperature. He had been in his usual state of generally good health until 2 days ago. He denies any recent injury to the right leg although he notes that since his coronary artery bypass graft (CABG) surgery, that leg is often slightly swollen at the end of the day but is never painful  4. Past medical history Any history of similar complaint in the past? Medical history: Other problems the patient has or had? Any chronic disease present like hypertension, diabetes… etc. Medications (even over the counter meds and herbals) if any taken in the past (dosage and duration)? Surgical history: Past hospitalizations and past surgeries? Make sure to put how old the patient was when they occurred. Include even those that occurred in childhood Allergies: Make sure to ask about medication allergies and the reaction that the patient has to them. Ask about latex, food and seasonal allergies Blood transfusion Pediatric: Birth history, Developmental Milestones, Immunizations? Gyne/Obstetric history if female, LMP between age 12-55 y  5. Family history It is important to establish whether there are any genetically transmitted diseases within families Any illness run in the family? Similar history in the family? Parents and siblings suffering with any chronic illness? Parents if died, how old and what they died of? You should be able to collect relevant family history depending upon the present illness Example: Patient has come due to anemia , Try to rule out sickle cell, thalassemia/ G6PD deficiency  6. Socioeconomic history Smoking history - amount, duration and type Drinking history - amount, duration and type Any drug addiction? Travel history Sexual history if suspected STI? Occupation, social and education background, financial situation Code status: Does the patient wish to have resuscitative measures taken in the event of their heart stopping, including chest compressions and/or endotracheal intubation: o DNR DNR—do not resuscitate o DNI DNI—do not intubate  7. System Review General Weakness Fatigue Anorexia Change of weight Fever Lumps Night sweats SKIN HEENT: Head, eye, ear, nose and throat  7. System Review…Cont. Gastrointestinal Cardiovascular Appetite (anorexia/weight Chest pain change) Paroxysmal Nocturnal Diet Dyspnea Nausea/vomiting Orthopnea Regurgitation/heart Short Of Breath burn/flatulence Cough/sputum Difficulty in swallowing Palpitations Abdominal pain/distension Cyanosis Change of bowel habit Hematemesis, melena Jaundice  7. System Review…Cont. Respiratory System Urinary System Cough(productive/dry) Frequency Sputum (color, amount, smell) Dysuria Hemoptysis Urgency Chest pain Hesitancy SOB/Dyspnea Terminal dribbling Tachypnea Nocturia Hoarseness Back/loin pain Wheezing Incontinence Character of urine: Color/ amount (polyuria) & timing Fever  7. System Review…Cont. Genital system Abnormal sensation Pain/ discomfort/ itching Change of behavior or psyche Discharge Musculoskeletal System Unusual bleeding Pain: Muscle, bone, joint Nervous System Swelling Visual/ Smell/Taste/Hearing/ Weakness/movement Speech Deformities Head ache Psychiatric Fits/Faints/Black outs/loss of consciousness Muscle weakness/ numbness/ paralysis  Now you've got your information Give a Summary and outline the likely possibilities Ask if you've understood the information correctly Ask if there is any other information that the patient wants you to know (‘Is there anything else you would like to raise or ask?’) Advise what your plan would be and be able to negotiate an agreed plan for further investigation and follow-up Check with the patient that they are in agreement with your plan Tell the patient that you will communicate this plan to other professionals involved in the care