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