Transcript Skills2

Approach to the Patient
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Introduce yourself with a friendly
greeting.
Give your name and status.
Explain the purpose of your interview.
Maintain good eye contact
Listen attentively.
Facilitate verbally and non-verbally.
Ask for background information
about the patient, which includes:
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Name
Age
Marital status and children (plus
menstruation and contraception (if
female)
Occupation.
Address.
Special habits of medical importance
History of current illness
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The main problem that made the patient
want to see the doctor.
The time and mode of onset of the
problem.
If the problem had changed since it first
happened
Comment upon
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Course: constant, intermittent,
progressive, regressive.
Aggravating and relieving factors if any.
Associated factors.
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Investigations and their results if done.
Treatments that have been undertaken.
Other symptoms of the relevant system.
Past medical history
Ask about
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Any previous similar episodes.
Any previous investigations.
Local endemic diseases (hepatitis,
bilharziasis.)
Other medical problems or conditions.
Any previous serious illnesses.
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Previous hospital admissions.
Previous operations.
Previous blood transfusion.
Injuries or accidents in the past.
Travel abroad.
History of drug intake and
allergies
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Medications actually taken
‘Over-the-counter’ drugs used by the
patient
Low-dose aspirin or Vitamins.
Oral contraceptive pills or HRT (hormone
replacement therapy).
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Any recent change in medications
If the patient usually forgets to take the
tablets
Any side effects of the medications
Any Allergies.
Drug abuse or recreational drug use.
Family history
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Significant illness in blood relatives
Transmissible diseases in all contacts
and relatives.
Opening Scenarios
Scenario 1
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You are a 20 year old male/female who
came to see the doctor about fatigue and
weight loss .
Scenario 2
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You are a 56 year old male/female who
came to see the doctor for indigestion.
You have discomfort in the middle of your
chest after eating and when you exercise.
Scenario 3
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You are a 60 year old male who came to
see the doctor for abdominal pain. You
have pain mostly after you eat and at
night.
Scenario 4
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A 24 year old medical student comes to
the doctor complaining of headache .