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Taking a Medical History: A surprisingly complicated procedure

Taking a Medical History: A surprisingly complicated procedure. Sean Reed, M.D. Assistant Professor Department of Family Medicine. Content of Medical History. Chief Complaint History of Present Illness Past Medical History Family History Social History (Patient Profile) Review of Systems.

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Taking a Medical History: A surprisingly complicated procedure

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  1. Taking a Medical History:A surprisingly complicated procedure Sean Reed, M.D. Assistant Professor Department of Family Medicine

  2. Content of Medical History • Chief Complaint • History of Present Illness • Past Medical History • Family History • Social History (Patient Profile) • Review of Systems

  3. Feel like you are getting only half of a very complicated story MYSTERY You’re not at all sure where the story is going and you are afraid of wasting time You understand what the patient is saying, but you are not sure what is going on

  4. Chief Complaint (CC) • Patient’s main reason to seek care • Agenda setting • Hidden agendas

  5. Chief Complaint: … Family history of diabetes “My wife made the appointment for me” “I can’t find my penis” … Congestive heart failure “Cell phone injury” … Five sutures to the forehead and a tetanus shot

  6. “Is there something in particular that you are worried about?”

  7. Power Tools/Techniques • SUMMARIZE: • Feedback to patient your understanding of story • If you are lost • If you are uncertain • If done/transition BENEFITS: Body posture and movements Eye contact Facial expression Inflection, tone of voice and rate of speech Touch Space between doctor and patient FOUCS: Facilitations Open-ended questions Clarification and direction Understanding by checking Surveying problems AVOID: leading questions multiple questions

  8. Getting started • What brings you in today? • How can I try and help today? • What would you like to discuss today? • I see that you have told the nurse…

  9. History of Present Illness (HPI): Physician-centered framework: 7 Symptom characteristics • Location • Quality • Severity • Timing • Setting/context • Modifying factors • Associated symptoms

  10. Pain History (“OPQRST”): • Onset and Occasion when symptom first was noticed • Provocative and Palliative factors • Quality and/or Quantity of symptom • Region of body and Radiation to other areas • Severity of symptom (0 to 10 scale, if applicable) and associated Symptoms • Time (duration) and Temporal associations (what is going on when symptom occurs)

  11. Major illnesses Hospitalizations Surgeries Significant injuries Medications Allergies Immunizations Transfusions Gynecologic and obstetric history Psychiatric history Past Medical History

  12. Past Medical History Medical Illnesses – identify chronic illnesses Hospitalizations - approximate dates Surgeries - approximate dates/reasons (ex: hysterectomy – benign or malignant?) Significant injuries

  13. Medications name, dosage, frequency, reason OTC, herbal, vitamins, supplements Other alternative medicine therapies Allergies – describe reaction Immunizations Transfusions Gyn and Ob history LMP, birth control use Past psychiatric history Past Medical History

  14. Family History • Current health of family • Specific familial diseases • Other family members with similar illnesses

  15. “Patients rarely volunteer a family history of mental illness or addiction”

  16. Social History / Patient Profile How do lifestyle or personality traits: • Contribute to causality of illness? • Aggravate or limit severity of illness • Interfere or help with getting well • The “usual day”

  17. Demographic information Occupational and educational history Military Travel history Refugee history Health Habits Smoking, Alcohol, Drug use Exercise Diet Sexual history Significant relationships Spiritual, cultural and health beliefs Social History/Patient Profile

  18. What do you do for a living? What do you do for fun?

  19. Uncover other medical problems Identify symptoms that may be related to presenting symptoms Move from general to specific questions Positive responses need further clarification Review of Systems

  20. SUMMARY Interviewing gems Is there something in particular that you are worried about? What do you do for a living? What do you do for fun? Don’t forget your power tools / techniques 7 Symptom characteristics • Location Setting/context • Quality Modifying factors • Severity Associated symptoms • Timing Summarize the visit Ask for questions Describe next step involve patient, if decision needed

  21. Thank you for listening

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