Dr Raj

History
Physical Examination
Reports of Investigations and Lab data
Differential Diagnosis
Diagnostic plan
Therapeutic plan
 Source of History:
Patient Demographics:
Name
Age or DOB
Gender
Religion/race/sect
Occupation
address

History- what the patient brings to you

Comprehensive History- Information patient provides
you with (some is useful, not all). You must make
concise par.
Use chronological order of history (ex. 2004-2016)
 SYMPTOM- WHAT patient tells you, based on
patient history, do NOT use medical terms,
use words patient uses, derived after history
taking (SUBJECTIVE)
SIGN- determined after clinical examination
(OBJECTIVE)
 Knock
Ask patient full name, then ask what they
would like to be addressed as
Introduce yourself to patient
State name and role, purpose
So what brings you here today
ANSWER: Chief Complaint

*ensure patient is comfortable*

- All symptoms/ Patients problems in his own
words for which he is seeking treatment.
Document story/ 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
 Pain as example:
Site
Onset
Character
Radiation
Associated factors
Timing
Exacerbating and Relieving factors
Severity
 Childhood Illness
-MMR, chicken pox
- Sterility a result of mumps (ask)
- Mitral Stenosis can date back to: History of repeated chest infection/ sore throat (cause
of post streptococcal infection)
- Glomerulonephritis can date back to Skin infections

Adult Illness
Medical
hypertension, diabetes, cholesterol/ medical details of their previous hospital
admittance
lnfection: Typhoid, Ebola
Surgical: Appendectomy or herniation?
Obstetric /Gynecological
*ASK EVERY SINGLE WOMAN LMP*
gravida (# of fertiliaztions- only 1st trimester), para (full term), abortion, living,
stillbirth

Immunizations
If they say yes, yes if they say anything else, NO
Can right history of allergy her. presenting illness
 Abortion (mtp)
Occurs automatically
Before 20 weeks

Still birth
Could be full term
never took their first breath
 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
Any first family member, age of death and
reason for death
Ex. Huntingtons chorea OR
athlete suddenly dies of MI, parent may have
had history of cardiomyopathy
 Lifestyle
Habits and addictions
Education and job satisfaction
Family life and Sexual life- polygamous
monogamous? STDs
Diet and exercise
Financial situations
Social and religious well being
C- cutting down
Has patient ever thought of cutting down?

A- Annoyed
Patient gets annoyed when ppl tell them to cut off

G- Next morning guilt

E- Eye opener
Cant open eyes without having drink

2/4 YES Advise counseling

 How many cigarettes per day?
How many packs per day?
1Pack year, 10 pack year
How many years?
 Short questions where the patient can answer
in Yes or No

Set of questions focusing each systems

 Vitals and general survey

Focused examination
 Upper Limb

Lower Limb
Its is skilled process of getting relevant
information from the patient which can help
in the rendering service to the patient.
 Active listening

Empathic response

Guided questioning

Non verbal communication

 Validation

Reassurance

Partnering

Summarization
 Transitions

Empowering patient
 Preparation.

Greeting patient and establishing rapport.

Establishing Agenda

Inviting Patient story and exploring patient

perspective (FIFE)
 Identifying and responding to the patients
Emotional cues

Expanding and clarifying the patients 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.
 Self-Awareness

Respectful communication

Collaborative partnerships
 Challenging patients

The silent patient.

The Confusing patient.
The patient with altered capacity.
The Talkative Patient.
The Crying patient
 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