Curriculum Vitae of Jose Rizal
History Taking Skills
Grzegorz Chodkowski (MD)
Riga, Radisson SAS
2009
History Taking Format
– Chief complaint – History of present illness (HPI) – Past medical history, which includes • Childhood • Medical • Surgical • OB/GYN • Psychiatric – Family history – Medications – Allergies – Personal/social history – Review of systems
Chief complaint problem / condition that motivated patient to seek care
To elicit the chief complaint, ask broad questions: – What brings you in today? – Tell me what has been going on. – What seems to be the problem? – What are your complaints?
History of the present illness (HPI)
• Patient's age, sex, occupation • Symptoms (or immediate cause of admission) • Chronology and the seven characteristics of the current symptoms: -Anatomic location -Quality -Quantity or severity -Timing -Setting in which the symptoms occur -Aggravating or relieving factors -Associated symptoms
History of the present illness (HPI)
Use facilitating expressions to encourage the patient to continue: – Mmm Hmm. – Yes? – Uh Huh? – And what else? - I am with you – Listening body language
Once the patient has had a chance to tell his or her story you can move on to more directed questions to clarify.
• • • • •
What is wrong? Where is it wrong? When did it start going wrong? How did it go wrong? Why do you think it is wrong?
Directed or closed questions
– Multiple choice • Do you have nausea, vomiting, constipation or diarrhea? • Is the pain sharp, dull or shooting? • Have you had this for days, weeks or months? • How long is the pain: minutes or hours? Important: Pause to wait for each response!!
Yes or No questions • Do you have diarrhea every day? • Do you have any allergies? Quantitive questions
• How many loose stools do you have a day?
Remember !
Avoid leading questions – You don’t smoke do you? – You haven’t had any chest pain? – Your wife is your only sexual partner, right? Avoid compound questions – Do you
Grzegorz Chodkowski (MD)
Riga, Radisson SAS
2009
History Taking Format
– Chief complaint – History of present illness (HPI) – Past medical history, which includes • Childhood • Medical • Surgical • OB/GYN • Psychiatric – Family history – Medications – Allergies – Personal/social history – Review of systems
Chief complaint problem / condition that motivated patient to seek care
To elicit the chief complaint, ask broad questions: – What brings you in today? – Tell me what has been going on. – What seems to be the problem? – What are your complaints?
History of the present illness (HPI)
• Patient's age, sex, occupation • Symptoms (or immediate cause of admission) • Chronology and the seven characteristics of the current symptoms: -Anatomic location -Quality -Quantity or severity -Timing -Setting in which the symptoms occur -Aggravating or relieving factors -Associated symptoms
History of the present illness (HPI)
Use facilitating expressions to encourage the patient to continue: – Mmm Hmm. – Yes? – Uh Huh? – And what else? - I am with you – Listening body language
Once the patient has had a chance to tell his or her story you can move on to more directed questions to clarify.
• • • • •
What is wrong? Where is it wrong? When did it start going wrong? How did it go wrong? Why do you think it is wrong?
Directed or closed questions
– Multiple choice • Do you have nausea, vomiting, constipation or diarrhea? • Is the pain sharp, dull or shooting? • Have you had this for days, weeks or months? • How long is the pain: minutes or hours? Important: Pause to wait for each response!!
Yes or No questions • Do you have diarrhea every day? • Do you have any allergies? Quantitive questions
• How many loose stools do you have a day?
Remember !
Avoid leading questions – You don’t smoke do you? – You haven’t had any chest pain? – Your wife is your only sexual partner, right? Avoid compound questions – Do you