Su8CL8? PlS1C8?

1AklnC
1alky CConnor
lmporLance of PlsLory 1aklng
W CbLalnlng an accuraLe hlsLory ls Lhe crlLlcal
flrsL sLep ln deLermlnlng Lhe eLlology of a
paLlenLs problem
W A large percenLage of Lhe Llme ( 70 ) you
wlll be able make a dlagnosls based on Lhe
hlsLory alone
Pow Lo 1AkL Lhe PlS1C8?
W 1he sense of whaL consLlLuLes lmporLanL daLa wlll
grow exponenLlally ln fuLure as you learn abouL
Lhe paLhophyslology of dlsease
W ?ou are already ln posesslon of Lhe Lools LhaL wlll
anable you Lo obLaln a good hlsLory
W And ablllLy Lo llsLen ask commonsense
quesLlon LhaL help deflne Lhe naLure of a
parLlcular problem
W A vasL sophlsLlcaLed fund of knowledge noL
needed Lo successfully lnLervlew paLlenL
Ceneral Approach
W lnLroduce yourself
W never forgeL paLlenL name
W ConfldenLlally and respecL paLlenL prlvacy
W 1ry Lo see Lhlngs from paLlenL polnL of vlew
W undersLand paLlenL menLal anxleLy lrrlLaLlon deppresslon
W Always exhlblL neuLral poslLlon
W LlsLenlng
W CuesLlonlng slmple / clear avold
medlcal Lerms lnLerupLlng dlrecL quesLlon and
summarlzlng
SLep of PlsLory 1aklng
W 1
sL
8LCC8u ( nASLCMu8 )
ldenLlLy CccupaLlon
MarrlLal SLaLus
Address
1lme uaLe of LxamlnaLlon
W C PlsLory of resenL C
W asLMed(and surg)Px ( 8lsk lacLors )
W SympLoms ln SysLem lnvolved
W urug Px
W SysLemaLlc 8evlew
W lamllyMPx
W SoclalPx
Chlef / rlmary ComplalnL
W Maln reason for vlslLlng / help
W usually SlnCLL sympLoms CCC more Lhen
one ( chesL paln palplLaLlon breaLh
shorLness )
W aLlenL descrle Lhe problem ln Lhelr own
words so recorded ln pL's own words
JhaL brlng you're here
Pow can l help you
JhaL seems Lo be Lhe problem
PlS1C8? Cl Aln
W S l1L
W C nSL1
W C PA8AC1L8
W 8 AulA1lCn
W A SSCClA1Lu S?S1LM
W 1 lML ln1LnSl1? 8LLA1lCnSPl
W L xACL88A1lnC / 8LLLAvlnC lAC1C8S
W S LvL8l1?
PlS1C8? Cl LuM
W J hen dld you 1
sL
noLlced Lhe lump
W J haL made you noLlced Lhe lump
W J haL sympLoms are assoclaLed wlLh Lhe
lump
W C has Lhe lump Change slnce you noLlced
W u oes Lhe lump ever ulsappear
W C have you noLlce have CLher lumps
anywhere else
PlS1C8? Cl uLCL8
W J hen dld you 1
sL
noLlced Lhe ulcer
W J haL made you noLlced Lhe ulcer
W J haL sympLom are assocoaLed wlLh Lhe ulcer
W C has Lhe ulcer Changed slnce you noLlced
W C have you had noLlced any CLher ulcers any
where else
PlsLory of resenL lllness
W LlaboraLe on Lhe chlef complalnL ln deLall
W Ask relevanL assoclaLed sympLoms
W Pave uu ln mlnd
W Lead Lhe conversaLlon LhoughLs
W ueclde welghL Lhe lmporLance of mlnor
complalnLs
PlsLory of resenL lllness ( 1lps )
W Avold medlcal Lermlnology make use of a
descrlpLlve language LhaL ls famlllar Lo Lhen
W Ask for each sympLom
PlsLory of resenLlng ComplalnL
W ln deLalls of presenL problem wlLh Llme of
onseL / mode of evoluLlon / any lnvesLlgaLlon
LreaLmenL ouLcome / any assoclaLed 've or
've sympLoms
W SequenLlal resenLaLlons
Always relay sLory ln days before admlsslon
narraLe ln deLalls
PlsLory of resenLlng ComplalnL
( eq of SequenL resenLaLlon )
W 8y LhaL evenlng Lhe fooL became swollen and
pL's was unable Lo walk nexL day pL's aLLend
hosp and Lhey gave hlm anLlbloLlcs Lhere ls no
effecL on hls condlLlon
W lf paLlenL has more Lhan one sympLom Lake
each symLom lndlvldually and follow lL
Lhrough fully menLlonlng slgnlflcanL negaLlve
as well
asL Medlcal / Surglcal PlsLory
W SLarL by asklng ll 1PL? PAvL An? MLulCAL
8C8LLMS ( slsLemaLlcally )
W asL Surglcal PlsLory
1lme place Lype problems
W PlsLory of 1rauma
1lme place Lype problems
urug PlsLory
W Always use generlc name Lrade name ln Lhe
brackeLs
uosage
1lmlng
Pow long
W uC nC1 lC8CL1 Lo menLlon
vlLamln LradlLonal / herbal alLernaLlve medlclne
W 8lood 1ransfuslon hlsLory
lamlly PlsLory
W Any famlllal dlsease / runnlng ln famllles
Cancer
l P u
uM
Schlzophrenla
AsLhma alblnlsm developmenL delay
W lnfecLlons runnlng ln famllles
Cholera Lyphold ln case of epldemlcs
Soclal PlsLory
W Smoklng hlsLory amounL duraLlon Lype
W Alcohol hlsLory amounL duraLlon Lype
W 8lsk for l P u
W Soclal class
W Pome condlLlon as
SanlLaLlon ( home surroundlng )
Anlmals / 8lrds
CLher 8elevanL PlsLory
W CbsLeLrlc / Cynecologlc hlsLory
W lmmunlzaLlon
W 1ravel / sexual hlsLory
W Screen for speclflc condlLlon
sa
PepaLlLls 8
eLc
SysLem 8evlew
W 1hls ls Lhe gulde noL Lo mlss anyLhlng
W Any slgnlflcanL flndlng should be moved Lo PC or
MP dependlng upon where you Lhlnk lL belongs
W uo noL forgeL Lo ask assoclaLed sympLoms of C
wlLh Lhe sysLem lnvolved
W Jhen glvlng verbal reporLs say no slgnlflcanL
flndlng on sysLem rvlew Lo show you dld lL
W Jhen wrlLlng up pL's noLes you should record
Lhe sysLems revlew so LhaL Lhe rellevlng docLors
know whaL sysLem you covered
SysLem 8evlew
( C L n L 8 A L )
W Jeakness
W laLlgue
W Anorexla
W Change of welghL
W lever / Chllls
W Lumps
W nlghL sweaLs
SysLem 8evlew
( CA8ulCvASCuLA8 )
W CPLS1 Aln
W A8Cx?SMAL nCC1u8nAL u?SnCLA
W C81PCnCLA
W SPC81 Cl 88LA1P ( SC8 )
W Cough / SpuLum ( plnklsh / lrank 8lood )
W Swelllng of Ankle
W alplLaLlon
W Cyanosls
SysLem 8evlew
( C l 1racL )
W AppeLlLe
W uleL
W nausea / vomlLlng
W 8egurglLaLlon / hearLburn / flaLulence
W ulfflculLy ln swallowlng
W Abdomlnal paln / dlsLenLlon
W Change of 8owel PabblL
W PemaLemesls melena hemaLochezla
W [aundlce
SysLem 8evlew
( 8LSl8A1C8? S?S1LM )
W CCuCP ( 8CuuC1lvL u8? )
W Su1uM ( CCLCu8 AMCun1 SMLLL )
W PLMC1?SlS
W CPLS1 Aln
W SC8 / u?SnCLA
W 1ACP?nCLA
W PCA8SLnLSS
W JPLLZlnC
SysLem 8evlew
( u8lnA8? S?S1LM )
W Lu1S
W PLMA1u8lA
W CCLlCk / uuLLAln
W lnCCn1lnLnCL
W lLvL8
SysLem 8evlew
( nL8vCuS S?S1LM )
W vlSuAL SMLLL 1AS1L
W PLAuACPL
W MuSCLL JLAknLSS / nuM8nLSS / A8AL?SLS
W A8nC8MAL SLnSA1lCn
W 18LMC8
W CPAnCL Cl 8LPAvlC8 Cl S?CPL
W A8LSlS
SysLem 8evlew
( CLnl1AL S?S1LM )
W Aln / ulSCCMlC81 / l1CPlnC
W ulSCPA8CL
W unuSuAL 8LLLulnC
W SLxuAL PlS1C8?
W MLnS18uAL PlS1C8? MLnA8CPL
W CCn18ACL1lCn
W C8S1L18lC PlS1C8?
SysLem 8evlew
SysLem 8evlew
( MuSCuLCSkLLL1AL S?S1LM )
W Aln MuSCLL 8CnL !Cln1
W SJLLLlnC
W JLAknLSS / MCvLMLn1
W uLlC8Ml1lLS
W CAl1
S C A
W Su8!LC1lvL
Pow pL's feels / Lhlnks abouL hlm Pow does he look
lncludes C and general appearance / condlLlon of paLlenL
W C8!LC1lvL
8elevanL polnLs of pL's complalnLs / vlLal slgns L / dally
welghL fluld balance dleL/lab lnLerpreLaLlon
W ASSLSSMLn1
Adress each acLlve problems afLer maklng a problems llsL
Make uu
W LAn
ManagemenL LreaLmenL furLher lnvesLlgaLlon followup
and rehablllLaLlon