Transcript HISTORY TAKING skill that must be developed by a doctor and not

http://meded.ucsd.edu/clinicalmed/introduc
tion.htm
HISTORY TAKING
skill that must be developed by a doctor and not memorized.
CHIEF COMPLAINT
• Each encounter MUST begin with the chief
complaint
• It is often documented in the pt’s own words
• It should be concise and describe the
symptoms, diagnosis or other reasons for the
encounter
• Example; “I have a urinary tract infection”
• The chief complaint may also include duration
of time
• Example; “ I have chest pain” x 3 hours
History of presenting illness (HPI)
• Is the subjective story given to you by the
patient in response to the questions you pose.
• It is to be preceded by an open-ended
question
• Open ended questions: are questions that
forces the patient to begin telling you a story.
• Open-ended questions cannot be answered
with a “yes” or “no” response.
• Example; “what brings you in today”,
Distracting patients
• Some patients may need to be redirected back
to the basis of their visit in the case of
deviation.
• MUST be done courteously
• Example: “I am sorry to interrupt, and if we
have time, we can come back to that, but can
you tell me when you had the chest pain last?”
CLOSE-ENDED QUESTIONS
• In patients unable to answer an open-ended
question.
• These questions require a yes/no or more specific
response.
• Example;
• Open-ended: “Describe the chest pain”
• Response: “I don’t know, it just hurts”
• Close-ended: “Is it sharp, dull, achy, pressure,
squeezing?”
• While asking the appropriate questions,
physicians must strive to understand exactly
what the patient means with their choice of
words.
Logical sequence
• Helps you to think without memorizing cos……
• One answer from the patient often leads to
the next question
• Note: your role is to keep the patient on track
with exploring his/her chief complaint while
also gaining sufficient information to obtain an
accurate diagnosis.
example
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Doctor: “Do you drink alcohol?”
Patient: “yes”
Doctor: “how often do you drink?”
Patient: “every day”
Doctor: “ how much do you drink in a day?”
Patient: “only one glass of wine a day?”
Components of HPI
• To prevent physicians from returning to the
room several times to ask the questions they
forgot the first time, there is a mnemonic
(CODIERSMMASSH)
MNEMONIC
OVERVIEW
SPECIFIC QUESTIONS
C- Chronology
Time frame showing the
sequence of events
Have you ever had this
before?
How has it changed?
What was the order of
symptoms
O- Onset
Occurrence
When did current
symptoms start?
D- Description
Duration
Describe it
Length of time
What does it feel like?
How long does it last?
I- Intensity
Scale
On a scale from 1 to 10,
how bad is the pain?
E- Exacerbating factors
What makes it worse?
R- Remitting factors
What makes it better?
S- Symptoms associated
Concurrent findings
For a cold: Do you have a
fever or chills?
M- Medications
Name, dose, frequency?
M- Medical history
Previous medical
diagnosis?
A- allergies
Food, environmental, drug
and what happens?
S- Surgical history
What? When?
S- Social history
Tobacco, ETOH, drugs,
occupation
H- Hospitalization
WHAT? WHERE?, WHEN?
• For female: ask when the FIRST Day Of Last
Menstrual Period (FDLNMP) occurred.
• Not all histories will have every component of
CODIERSMMASSH
REVIEW OF SYSTEM
• Is an inventory of symptoms related to the
body’s systems and documented separately
from “CODIERSMMASSH”
• Review of system mostly answer the question
of “ symptoms associated”