Medical HistoryMedical History

Dr.H.N.SarkerDr.H.N.Sarker

MBBS. FCPS (med). MACP(USA).MBBS. FCPS (med). MACP(USA).

MRCP (London). MRCPS(GLASGO)MRCP (London). MRCPS(GLASGO)

Associate professorAssociate professor

MedicineMedicine

• ““Patient suffers from disease but Patient suffers from disease but presents with symptoms”presents with symptoms”

Dr.Sarker.Dr.Sarker.

Cardiorespiratory Cardiorespiratory

• Chest pain Chest pain

• Intermittent claudication Intermittent claudication

• Palpitation Palpitation

• Ankle swelling Ankle swelling

• Orthopnoea Orthopnoea

Cardiorespiratory Cardiorespiratory

• Nocturnal dyspnoea Nocturnal dyspnoea

• Shortness of breath Shortness of breath

• Cough with or without sputum Cough with or without sputum

• Haemoptysis Haemoptysis

Gastrointestinal Gastrointestinal

• Abdominal pain Abdominal pain

• Dyspepsia Dyspepsia

• Dysphagia Dysphagia

• Nausea and/or vomiting Nausea and/or vomiting

• Change in appetite Change in appetite

Gastrointestinal Gastrointestinal

• Weight loss or gain Weight loss or gain

• Bowel pattern and any change Bowel pattern and any change

• Rectal bleeding Rectal bleeding

• Jaundice Jaundice

Genitourinary Genitourinary

• Haematuria Haematuria

• Nocturia Nocturia

• Frequency Frequency

• Dysuria Dysuria

• Menstrual irregularity - women Menstrual irregularity - women

• Urethral discharge - men Urethral discharge - men

Locomotor Locomotor

• Joint painJoint pain

• Joint swelling Joint swelling

• Change in mobility Change in mobility

Neurological Neurological

• Seizures Seizures

• Collapse or blackouts Collapse or blackouts

• Dizziness and loss of balance Dizziness and loss of balance

• Vision Vision

• Hearing Hearing

• Transient loss of function (vision, Transient loss of function (vision, speech, sight) speech, sight)

Neurological Neurological

• Paraesthesiae Paraesthesiae

• Weakness Weakness

• Wasting Wasting

• Spasms and involuntary movements Spasms and involuntary movements

• Pain in limbs and back Pain in limbs and back

• Headache Headache

Traditional history-taking Traditional history-taking model model

• Presenting complaint Presenting complaint

• History of presenting complaint History of presenting complaint

• Past medical historyPast medical history

• Drug history-Allergy historyDrug history-Allergy history

• Family historyFamily history

• Social historySocial history

• Systems reviewSystems review

The Calgary-Cambridge The Calgary-Cambridge framework framework

Initiating the sessionInitiating the session

• Begin by greeting the patient and Begin by greeting the patient and obtaining their name. obtaining their name.

• Introduce yourself, your role, and the Introduce yourself, your role, and the nature of the interview. nature of the interview.

• If appropriate, obtain verbal consent If appropriate, obtain verbal consent for the interview. for the interview.

• Communication skills in the medical Communication skills in the medical interviewinterview

Open questionsOpen questions allow patients to allow patients to express their own thoughts and feelings, e.g. express their own thoughts and feelings, e.g. 'How have you been since we last saw you?', 'How have you been since we last saw you?', 'Is there anything else that you want to 'Is there anything else that you want to mention?' mention?'

Closed questionsClosed questions are requests for are requests for factual information, e.g. 'When did this pain factual information, e.g. 'When did this pain start?' start?'

Leading questionsLeading questions invite specific invite specific responses and suggest options, e.g. 'You'll be responses and suggest options, e.g. 'You'll be glad when this treatment is over, won't you?' glad when this treatment is over, won't you?'

• Reflecting questionsReflecting questions help to develop or help to develop or expand topics, e.g. 'Can you tell me more expand topics, e.g. 'Can you tell me more about your family?' about your family?'

• Active listeningActive listening encourages further encourages further dialogue, e.g. 'Go on,' 'I see,' 'Hmm' etc. dialogue, e.g. 'Go on,' 'I see,' 'Hmm' etc.

• Requesting clarificationRequesting clarification encourages encourages further detail, e.g. 'How do mean?', 'In further detail, e.g. 'How do mean?', 'In what way?' etc. what way?' etc.

• SummarisingSummarising ensures accurate ensures accurate understanding, e.g. 'Tell me if I've got this understanding, e.g. 'Tell me if I've got this right.' right.'

Gathering information Gathering information

• Encourage the patient to tell the Encourage the patient to tell the story in their own words, from story in their own words, from beginning to end. beginning to end.

• Use open questioning initially; Tell Use open questioning initially; Tell me how your symptoms started?.me how your symptoms started?.

• Move on to use closed questions for Move on to use closed questions for details. details.

Open and closed questions Open and closed questions

Both types of question have their place. Both types of question have their place.

• Can we start with you telling me what Can we start with you telling me what has happened to bring you into has happened to bring you into hospital? (hospital? (OpeningOpening))

• Well, I've been getting this funny feeling in Well, I've been getting this funny feeling in my chest over the last few months. It's been my chest over the last few months. It's been getting worse and worse but it was really getting worse and worse but it was really awful this morning. I got really breathless awful this morning. I got really breathless and felt someone was crushing me. and felt someone was crushing me.

Open and closed questions Open and closed questions

• Tell me a bit more about the Tell me a bit more about the crushing feeling. (crushing feeling. (Open Open questioningquestioning))

• Well, it was here, across my chest. It Well, it was here, across my chest. It was sort of tight. was sort of tight.

• And did it go anywhere else? And did it go anywhere else? ((ClarifyingClarifying))

• No. Well, may be up here in my neck. No. Well, may be up here in my neck.

Open and closed questions Open and closed questions

• So what you are saying is that you had this So what you are saying is that you had this tight pain in your chest this morning that tight pain in your chest this morning that went on a long time and you felt it in your went on a long time and you felt it in your neck? (neck? (SummarizingSummarizing) . You said you've had ) . You said you've had the pain for the last few months. Can you tell the pain for the last few months. Can you tell me more? (me more? (Reflecting and open questioningReflecting and open questioning))

• Well, it was the same but not that bad, though it's Well, it was the same but not that bad, though it's

been getting worse recently. been getting worse recently.

Open and closed questions Open and closed questions

• Can you remember when it first started? (Can you remember when it first started? (ClarifyingClarifying)) • Oh, 3 or 4 months ago. Oh, 3 or 4 months ago.

• Does anything make it worse? (Does anything make it worse? (Open questioningOpen questioning)) • Well, if I go up steps or up hills that can bring it on.Well, if I go up steps or up hills that can bring it on.

• What do you do?What do you do? • Stop and sometimes take my puffer. Stop and sometimes take my puffer.

• Your what? (Your what? (ClarifyingClarifying)) • This spray the doctor gave me to put in my mouth. This spray the doctor gave me to put in my mouth.

• Can you show me it, please?Can you show me it, please? • OK.OK.

• And what does it do? (And what does it do? (ClarifyingClarifying)) • Well, it takes the pain away, but I get an awful Well, it takes the pain away, but I get an awful

headache with it. headache with it.

Open and closed questions Open and closed questions

• So, for a few months you've had So, for a few months you've had this tightness in your chest, which this tightness in your chest, which gets worse going up hills and gets worse going up hills and upstairs and which goes away if upstairs and which goes away if you use your spray. But today it you use your spray. But today it came on and lasted longer but felt came on and lasted longer but felt the same. Have I got that right? the same. Have I got that right? ((SummarizingSummarizing))

• No, it was much worse this morning. No, it was much worse this morning.

• Past medical historyPast medical history

• Drug history-Allergy historyDrug history-Allergy history

• Family historyFamily history

• Social historySocial history

• Systems reviewSystems review