لجنة الطب البشري رؤية تنير دروب تميزكم
Clinical skills
History Taking
Done by: Hasan Zreiqat
ا صبرٌ جميل .لا تفقد صبرك مهمَا تأخر عليك الفرَج، فما بين حلمك و تحقيقه إلاا
History Taking
First of all,
We will start with the basics of clinical procedures.
Before examining the patient you should do the following steps.
1-Introducing yourself
2-Gaining consent
3-performing hand hygiene
4-rolling up your sleeves and remove your watch
5-providing privacy
:definitionsImportant skills in medical consultation and there
Open and closed question techniques: Move appropriately from
open (answer is long) to closed (yes/no) questions.
Screening: Asking if there is anything else to ensure no points are
missed
Active Listening: Utilizing wait time, non-verbal cues, facilitative
response (um... go on...)
Signposting: Progress from one section of the medical interview to
another by explaining what you want to discuss next
Facilitative Response: Nodding head, using “um, ah-ha, go on” to
encourage patient to keep talking but showing that you are
listening
Clarification: Ask patient to rephrase or check understanding of
words or statements that are unclear from the patient
Using easily understood language: Avoid using medical words
that patients will not understand
Establish sequence of events: Discover logical sequence of the
patient's story.
Incorporate patient's perspective: Discover patient's ideas,
concerns, expectations, effects on life
Develop rapport: Building the relationship with the patient so that
the doctor and patient can relate well to each other
o Accept patient's views and feelings non-judgmentally
o Use empathy, acknowledge patient's feelings
o Provide support
o Deal sensitively with patient
Involve patient: Explain to the patient the rationale for asking
certain questions.
Summarizing: Using your own words to shorten what has been
said, but still containing the main points.
Empathy: The experience of understanding another person's
condition from their perspective.
Starting consultation
o Make sure you are talking to the correct patient
o Introduce your self
o Handshake
o Look at the patient’s records and at any transfer or admission
letters before starting the conversation
The information that you should ask the patient about it:
Patient’s Profile
Personal information about patient, and that includes:
• Name • Age • Gender • Occupation
• Address • Marital status
• The way of presentation of the patient to the hospital
The presenting complaint
The primary symptom that a patient states as the reason for
seeking medical care.
History of presenting complaint
It refers to a detailed interview prompted by the chief complaint
or presenting symptom
Pain
There are principles to ask about pain (SOCRATES) which are:
o Site (somatic pain is well localized while visceral pain is diffuse)
o Onset (speed of onset)
o Character (describing the pain- dull/ sharp/ stabbing/ burning)
o Radiation (referred pain vs shifting pain vs radiating pain) o
Associated symptoms
o Timing (course- increasing, decreasing… , pattern- continuous,
episodic…)
o Exacerbating and relieving factors (activities, medications,
posture, food…)
o Severity (usually difficult to assess- because of the variations in
pain threshold- and more important in evaluating the progress of
pain)
Past history
It includes past medical and past surgical history
Allergies & Drug History
Asking about any prescribed drugs and medications
Family history
Asking about any illnesses that run in family, or about any sudden
death
Social history
Helps to understand the context of the patient’s life and possible
relevant factors
Social history
1: upbringing 2: home life 3: finance 4: house
5: occupation 6: relationship 7: sexual history 8: exercise
9: substance abuse 10.leisure 11: domestic circumstances
Patient’s perspective
Patient’s ideas and feelings of has happened to him/her
Abbreviated in FIFE
• Feelings related to illness
• Ideas on what is happening to him
• Functioning in terms of impact on daily life
• Expectations of illness and doctor
Systemic review
Uncovers symptoms that may have been forgotten (ask ‘Is there
anything you would like to tell me about?’)
Scenario :
What should you do in OSCE?
Doctor : Dr Patient: P Emergency : ER
When you enter the room you should introduce yourself to your
patient for example:
Dr: Hi, good morning I am doctor Hasan, I am your doctor for today
…. What is your name?
P: My name is Leen
Dr: May I ask you some questions please? (Gaining consent)
P: Yes, for sure
Dr: How old are you?
P: I am 20 years old
Dr: Where do you live?
P: In Amman
Dr: What do you do for work?
P: I am a student in the HU
Dr: Are you married?
P: No I am not
Dr: Why did you come to the hospital today and how?
P: I came by car to the ER because of my bad chest pain
Dr: ahaaa Is there anything else?
P: shortness of breath
Dr: Which is more sever, your shortness of breath or your chest
pain?
P: chest pain
Dr: okay leen let's talk about your chest pain
Dr: Where is the pain?
P: In the left of my chest
Dr: When did it start?
P: A week ago
Dr: Was it sudden or gradual?
P: Sudden pain
Dr: Can you describe the pain for me?
P: It is a sharp pain
Dr: Does it moves any where?
P: No
Dr: Does it come and go?
P: It comes in attacks and maybe last for 5 minutes
Dr: What makes it worse?
P: When I lay flat
Dr: What makes it better?
On a scale for 1 to 10, where 10 is the worst pain, how severe is
yours
P: 8
Dr: Is there anything you want to add
P: No doc.
Now you will summarize
Dr: So you have a sharp pain, in your left chest. It started a week
ago, it was a sudden pain, comes and goes in episodes, lying flat
makes it worse and it is 8 out of 10
Now you will ask about past medical history
Dr: Ok Lets move on to your past medical history
P: Ok
Dr: Have you been seriously ill before?
P: No
Dr: Have you been admitted to a hospital?
P: Yes
Dr: What for?
P: To remove my appendix
Dr: How long did you stay there?
P: Two days
Dr: Do you feel better after surgery ?
P: Yes
Dr: Have you had any other surgeries?
P: No, just appendectomy
Dr: Do you have any sort of diseases, blood pressure, diabetes?
P: No
Dr: Now I want to know more about your medications and allergies
P: Ok
Dr: Do you take any sort of medication?
P: No
Dr: Are you allergic to anything?
P: Yes to penicillin
Dr: Lets know more about your family …. Are your parents doing
well ?
P: Previously my father had the same pain and he made a catch to
open an occluded artery
Dr: Is there any certain illness, like blood pressure , heart attacks ,
diabetes
P: No
Dr: I would like to know more about your social life if you do not
mind
P: Ok
Dr: Do you smoke leen?
P: No
Dr: I am really sorry to ask this, but do you drink alcohol?
P: No
Dr: Do you consume illegal drugs?
P: No
Dr: Do you live in an apartment or separate house?
P: Separate house
Dr: Ok, do you have any pet or animal at home?
P: Yes, a cat
Dr: I have I cat too
Dr: Have you travelled recently?
P: No
Dr: Ok, leen what do you think that might be causing this pain
P: Maybe a problem in my heart
Dr: Aha, what concerns you about this?
P: I am worried, as I told you my father had a catch
Dr: How has this been affecting your life?
P: I was not able to go to college lately
Dr: Okay , What do you expect me to do for you ?
P: Do some examinations and test for me
Dr: Okay leen I will do my best, thank you.
P: Thank you Dr.
.إن الإتجاه الذي يبدأ مع التعلم سوف يكون من شأنهِِ أن يحُدد حياة المرء في المستقبل