Dr. Abdelmonem Gado, MS Surgery, FRCSI Consultant Paediatric Surgeon, Division of Paediatric...
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Transcript of Dr. Abdelmonem Gado, MS Surgery, FRCSI Consultant Paediatric Surgeon, Division of Paediatric...
![Page 1: Dr. Abdelmonem Gado, MS Surgery, FRCSI Consultant Paediatric Surgeon, Division of Paediatric Surgery, Department of Surgery.](https://reader033.fdocuments.in/reader033/viewer/2022051620/56649e625503460f94b5e103/html5/thumbnails/1.jpg)
An Introduction for History Taking
Dr. Abdelmonem Gado, MS Surgery, FRCSIConsultant Paediatric Surgeon, Division of
Paediatric Surgery, Department of Surgery
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•Your professional obligations, the expectation placed upon you by the public, the law and your colleagues, start on your first day as a student and continue throughout your working life.
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• The qualities that patients look for in a doctor:•Humaneness•Competence•Accuracy•Honesty•Openness•Responsiveness•Trusthworthiness•Involving the patient in the decision making process •Time and listen
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Guidelines and Certain Rules
-Language:- Learn to speed read- A good clinician is someone who interested in
people-Put yourself in situation of the patient or their
relatives-The best doctor are invariably the most humble and -good observer-Dress, Demeanour and confidentiality to establish
successful patient – doctor relationship
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Set-up:-Where will you see your patient?-Keep always quite and private space-How long this interview?-How will you sit?
Hand washing and Cleanliness:- Is the single most effective way to prevent the spread of infection
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Infections that can be transmitted on the hands of healthcare workers”-Healthcare – acquired infections:
-MRSA - Clostridium difficile-Diarrheal infection:
-Salmonella - Shigella - E.coli - Noro virus- Respiratory Infection:
- Influenza - Common cold - Resp. Syncytial virus (RSV)
- Other Infections: Hepatitis A
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Communication Skills, How?-Maintain good eye contact-Active listening, then write-Encourage verbal or non verbal communication-Avoiding jargon-Ability to discuss difficult issues-Going at a place that is comfortable for the patient-Diligent and frequent practice
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Introduce yourself:-I am Mr…., I am 3rd year medical student-I have been asked to talk to you and examine you with some of my colleagues-It might take 30 minutes-Privacy -Notes (it does not mean I’m not listening to you-Are you happy with all that?
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Things to remember:-Never write while talking-See the patient walking-See the accompanying person (mother, wife, friend)
-Can often provide valuable information -However, many patients are inhibited from discussing their problems by the presence of third person
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Guide the conversation:-Explain what you are doing, and why you are doing it, at all stages- patients know more about their complaints than you, but cannot interpret their significance:- Interpreter – short and simple questions- Leading questions - one answer- open questions- Example : Does the pain ever move?- Always ask the questions in the right way.
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Principle of History taking in Surgery:
History taking? the key step in surgical diagnosis.
Varies according to the complain ? specific histories ? surgical specialty
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Two types of history in surgical practice:
Out-pt or emergency room history ?specific complaint is pinpointed ? diagnosis
Clerking of pt admitted for elective surgery object
? to assess that the treatment planned correctly indicated and pt is suitable for that operation.
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History Taking• Information gathered during patient interview
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Components of Patient History
- Date and Time - Chief Complaint
- Identifying data - Present illness
- Source of referral - Past medical and surgical history
- Source of history - Family History- Social History- Drug History
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History TakingI. Personal Information
- Age, Sex, marital status, occupation nationality, residence, etc..
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HISTORY cont..:2) Present complain:
- open question- closed question- write in patients words
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Chief Complaint
• Symptoms that caused patient to seek care• Often:
• Pain• Abnormal function• Change in normal state• Unusual observation made by patient (e.g., heart palpitations)
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History:3) History of present illness (Complaint)
- Provide full, clear, chronological account of symptoms
- In scientific term- Similar attacks- Determine the abnormal system
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HISTORY cont..:
4) Remaining question of abnormal system
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HISTORY cont.:
5) Systemic direct question:◦ it reveals the presence of other disorders
of which the patient was unaware, or thought irrelevant
◦ -ve answers are as important as +ve answers
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The Alimentary System
• Appetite - Heartburn• Diet - Vomiting• Weight - Haematemesis• Teeth and Taste - Indigestion• Swallowing - Abdominal pain• Regurgitation - Defecation• Flatulence - Change of skin
Color
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Respiratory System-Cough- Sputum- Haemoptysis- Dyspnea- Orthopnea- Chest pain
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Cardio Vascular System- Breathlessness- Orthopnea- Paroxy swal noctural dyspnea- Pain- Palpitations- Cough and sputum- Dizziness and headaches- Ankle swelling
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Urogenital system- Pain - Scrotum & urethra- Oedema - Menstruation- Thirst - Dyspareunia- Micturation - Breast- Urine –haematuria - Secondary sex character
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Nervous system and musculoskeletal system
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General state of health:◦ Childhood illnesses◦ Adult illnesses◦ Accident and injuries◦ Surgeries or hospitalizations
Significant Past History
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Health of immediate family◦ High blood pressure, heart disease, contagious
illnesses
Potential for hereditary diseases
Family History
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Marital status Occupation Residency The lesiure activities Habits (smoking, alcohol,etc) Travelled abroad.
Social History
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Alcohol or drug use
Physical abuse or violence
Sexual issues
Sensitive Topics
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Respect patient privacy
Be direct and firm
Avoid confrontation
Be nonjudgmental
Use appropriate language
Document carefully◦ Use patient’s words when possible
Sensitive Questions Guidelines
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Silence
Overly talkative patients
Patients with multiple symptoms
Anxious patients
Special Challenges
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Anger and hostility Intoxication Crying Depression Sexually attractive or seductive patients Confusing behavior or histories Limited intelligence Developmental disabilities
Special Challenges
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May result from:◦ Social or cultural differences◦ Sight, speech, or hearing impairments
Attempt to find assistance to aid in communication
Barriers to Communication
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Pain Lump
Commonest complains in Surgery
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History of pain-The site-Onset-Duration -Severity-Nature of the pain-Progression of the pain-Relieving and exacerbation factors-Radiation and refering pain
Commonest complains in Surgery
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History of a lump-Site.-Duration.-What made the patient notice the lump.-course of the lump.-Associated symptoms.-Other lumps
Commonest complains in Surgery
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- QUIZ
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QUESTIONS?
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- THANK YOU!