Professional Documents
Culture Documents
3 Medical History
3 Medical History
herni suprapti
...
Goerge
Engel - 1973
the
anxieties
concerns
The
The
Beginning an interview :
establishing rapport
Mr
Often
When
Name
Address
Age
Occupation
Marital status
Sometimes
When
Their
understanding of arthritis
might not be the same as yours.
Don't
Well,
I have Osler-Rendu-Weber
disease.
I'm
The
DR KITE
You've told me that you have had trouble passing
water. Before we discuss that further, could you
tell me if you have any other problems?
MR BROWN
Yes, I've been a bit unsteady on my feet
recently and a bit short of breath when climbing
stairs, and I'm worried about my wife who has
just had a stroke.
It
Make
This
It
In
Of
But
WHAT :
What does it feel like ? What brings it on ?
WHERE:
Show me where it is.
HOW :
How bad is it ? How is it altered by food,
exertion, etc. ?
WHEN :
When did it start ? When does it occur ? (How
often ? How long for ?)
WHY :
Why do you think you have got it ?
WHO :
Who is affected by it ?
timing : when ?
You will need to know
when the pain began
how it started
its duration
how often it occurs
how it ended
Sometimes it is helpful to ask the patient to recall the onset of the
problem and describe how it has developed since then. If they
have had numerous different episodes, ask them to describe a
typical one.
location : where ?
This
radiation : where ?
It
MR DAWES - DR BUCK
DR BUCK - Mr DAWES
When you had your chest pain, did you have any other
symptoms at the time?
Yes, my heart was racing and I felt a bit short of
breath.
DR ROSS
You have told me a lot about your abdominal pain and the way
it's associated with wind and problems in passing your motions.
Could you tell me now about what you are usually doing when the
pain comes on.
MRS ALTON
I've been thinking about that. I never get this problem when
I'm on holiday - it seems to happen mostly when I'm busy at
work, or when we're expecting visitors at home.
Modifying factors :
how is it affected by ... ?
Find out what makes the symptoms worse and what makes them
better :
When you have the pain, is there anything that makes it better?
It's better when I've passed wind or had my bowels open.
How does what you eat affect it?
I used to eat lots of vegetables and fruit, but I've cut that
down and the pain seems to be a bit better.
Do you ever take any medicines for the pain?
No. I tried paracetamol once, but that didn't seem to make any
difference.
The
You may have found out a lot about the impact of the
problem on the patient's life from their answers to
your previous questions.
You should look specifically at the effect on their :
mood
relationships, particularly with spouse and close
family
job
leisure and social life
sexual activity.
It
The
Examples
include :
Cardiovascular :
Could
Respiratory :
Do
Genito-urinary :
Do
speech
You
Mood
Thought content
Patients
suicide
Question :
'Could
Cognitive function
Patient's
Tests
DR
ROSS
You've
MRS ALTON
Let
DR
ROSS
Have
MRS ALTON
No,
I haven't.
DR
ROSS
And
MRS ALTON
Only
DR
ROSS
And
MRS ALTON
No
DR ROSS
MRS ALTON
MRS ALTON
Well, yes. I slipped on the ice and broke my leg about 10 years
ago. Actually I was in hospital then for several weeks - I'd
forgotten that
DR ROSS
DR ROSS
There
These
Family history
This
example
Mrs Alton
When
if
DR
ROSS
I'm
MRS ALTON
He
DR
ROSS
And
your mother ?
MRS ALTON
Oh,
Taking
disease
high blood pressure
diabetes
You
Social history
build
Social history
interpret
patient profile
lifestyle (particularly risk factors)
sources of both stress and support
Patient profile
information
about
family
life
other close relationships
work and daily activities
Suitable
"Could
Occupational history
is
e.g.
Occupational history
The
Lifestyle
The
Smoking history
Do
you smoke?
What do you smoke?
How much do you smoke?
How long have you smoked like this?
If the patient is a non-smoker, ask if they
have smoked in the past and if so, for how
long?
Drinking history
If
what
they drink
how much during an average week
DR BUCK
MR DAWES
A few pints? It would help me if you could go over the past week and
give me an idea of how much you drank each evening?
MR DAWES
Mostly beer: I go down to the pub most nights to have a few pints with
my mates.
DR BUCK
MR DAWES
DR BUCK
I'd like to ask you now about your drinking habits. Can you tell me if you
drink alcohol?
Well, let me see - I 'went down to the pub perhaps four times last week
and drank about three pints each evening.
DR BUCK
Drug history
all
Sources of stress
Health
questions
"Could
closing an interview
summarise
rapport
listen actively
ask mainly open questions
pick up and respond to verbal and nonverbal cues
facilitate or help if the patient gets stuck
summarise and check for accuracy
Make
up
Preparation
Obtain
Presentation
Relax
Speak
Follow up
If
Key points
personal details
presenting problem(s)
history of presenting problem(s)
review of body systems
past medical history
family history
social history
summarise and conclude interview