dr raj. history physical examination reports of investigations and lab data differential...

History and Clinical Interviewing

Dr Raj

History Physical Examination Reports of Investigations and Lab data Differential Diagnosis Diagnostic plan Therapeutic plan

Parts of the patient record

Source of History: Patient Demographics:

NameAge or DOBGenderReligion/race/sectOccupationaddress

History

Patients problems in his own words for which he is seeking treatment.

Chief complaints

Story or narrative of patients problems in

chronological order.

Each symptom should be in separate paragraph with description of the symptom.

What immediate measures were taken to relieve the symptoms

Present Illness or History of presenting illness

Pain as example: Site Onset Character Radiation Associated factors Timing Exacerbating and Relieving factors Severity

Childhood Illness

Adult IllnessMedicalSurgicalObstetric /Gynecological

Immunizations

Past History

Illness and cause of death in blood relatives

Pedigree chart

Important in genetically transmitted diseases like cancer or enzyme disorders as well as lifestyle diseases

Family History

Lifestyle Habits and addictions Education and job satisfaction Family life and Sexual life Diet and exercise Financial situations Social and religious well being

Personal and Social history

Short questions where the patient can answer in “Yes” or “ No”

Set of questions focusing each systems

Review of system

Vitals and general survey

Focused examination

Physical Examination

Upper Limb

Lower Limb

General Survey and Focussed Examination

Clinical Reasoning and assessment

Its is skilled process of getting relevant

information from the patient which can help in the rendering service to the patient.

Clinical Interviewing

Active listening

Empathic response

Guided questioning

Non verbal communication

Fundamentals of skilled interviewing

Validation

Reassurance

Partnering

Summarization

Transitions

Empowering patient

Preparation.

Greeting patient and establishing rapport.

Establishing Agenda

Inviting Patient story and exploring patient perspective (FIFE)

Sequence of Interview

Identifying and responding to the patients Emotional cues

Expanding and clarifying the patient’s story

Generating and Testing Diagnostic Hypotheses.

Sharing treatment plan.

Closing the interview

Taking time for self reflection

Demonstrating cultural humility.

Cultural competence?

A set of attitude, skills , behaviors, and policies that enable organizations and staff to work effectively in cross-cultural situations.

Cultural Context of the Interview

Self-Awareness

Respectful communication

Collaborative partnerships

Cultural Context of the Interview

Challenging patients

The silent patient. The Confusing patient. The patient with altered capacity. The Talkative Patient. The Crying patient

Advaced Interviewing

The angry and disriptive patient. The patient with a language barrier.

(INTERPRET) The patient with low literacy. The patient with hearing loss. The seductive patient

Thank you