M1: Medical History

Question 0

First step in establishing patient ________ and building a good _______________.

Answer 0

Rapport. Doctor-Patient Relationship.

Question 1

Can already be made from a good clinical history 80% of the time

Answer 1

Diagnosis

Question 2

Patients report the story of an illness as they have lived and remembered it. Varies with age, socioeconomic status, culture and experiences.

Answer 2

History

Question 3

Are a universal human experience, but often have unique personal meaning.

Answer 3

Symptoms

Question 4

Fact finding & Investigation about the disease. Observation of patient’s behavior and what the illness means to them. A skill and an art.

Answer 4

History taking

Question 5

Requirements for History taking: Ability to _________.

Answer 5

Listen

Question 6

Requirements for History taking: Ask ________ questions.

Answer 6

Common sense

Question 7

Requirements for History taking: Good _________.

Answer 7

Intentions

Question 8

True statement

Answer 8

Fact

Question 9

Consists of facts that are arranged in a useful manner

Answer 9

Information

Question 10

A history is not simply a collection of facts. The facts must be placed in a form that makes them ________.

Answer 10

Informative

Question 11

Is the explanation the clinician brings to the symptoms. Leads tp the diagnosis and management plan.

Answer 11

Disease

Question 12

Is how the patient experience the symptoms shaped by previous experiences, how symptoms affect daily living, culture, age and expectations about medical care. _________ must take into account both.

Answer 12

Illness. Health History.

Question 13

Date and time of examination. Identifying data: name, age, sex, ethnicity, civil status, religion and address. Source of history and reliability. Sources of referral.

Answer 13

General Data

Question 14

Main reason the patient seeks medical attention. Usually have a single symptom, but may be more. Recorded in patient’s own words. Be careful about recording a diagnosis in this areas.

Answer 14

Chief complaint

Question 15

Clear, chronological narrative account of present problem. Detailed progression and regression of symptoms very important. Includes prior investigation, confinements and treatments if any. Sequential presentation.

Answer 15

History of Present Illness

Question 16

HPI: Avoid __________.

Answer 16

Medical terminology

Question 17

HPI: Must be written or presented in ________ & grammatically correct language.

Answer 17

Concise

Question 18

HPI: Ability to discern what is ________ & ________ data will come as you learn more about the pathophysiology of the disease.

Answer 18

Essential & Important

Question 19

Ask about symptoms in the other major body systems NOT mentioned in HPI.

Answer 19

Review of Systems

Question 20

Review of Systems: Identify ________ the patient has not mentioned so that they are not missed.

Answer 20

Problem

Question 21

Review of Systems: Identify ________ of other diseases the patient may not know about.

Answer 21

Symptoms

Question 22

Review of Systems: Identify symptoms which may be _________ for present illness.

Answer 22

Risk factors

Question 23

If symptoms appear to be related to chief complaint, move ROS to

Answer 23

HPI

Question 24

Is the key for a good ROS

Answer 24

Systematic Approach

Question 25

Controversial position in Health History. May be done during Physical Exam. Include pertinent positives and negatives.

Answer 25

Review of Systems

Question 26

Present known medical problems. Note when diagnosed, meds if any & regular check-up. Current medications with doses, previous illness/confinement/surgery/BT, allergies and immunizations.

Answer 26

Past Medical History

Question 27

Diseases among first or second degree relatives of the patient, listed according to disease, include age at onset and if cause of death. Review certain conditions (HPN, HD, DM, Ca, Thyroid disease, Seizure & Psychiatric disorders) if considering infectious disease, may require if any family member also have symptoms.

Answer 27

Family History

Question 28

Includes smoking, alcohol intake, illicit drug use, work/occupation, diet & exercise, water supply & living conditions if necessary, sexual preference & activity and OB-Gyne History.

Answer 28

Personal and Social History

Question 29

Interview sequence: ________ the patient and _______ rapport.

Answer 29

Greeting. Establishing.

Question 30

Interview sequence: ________ the patient's story.

Answer 30

Inviting

Question 31

Interview sequence: Establishing the ________ for the interview.

Answer 31

Agenda

Question 32

Interview sequence: ________ and ________ the patient's story, generating and testing diagnostic hypotheses.

Answer 32

Expanding & Clarifying

Question 33

Interview sequence: Creating a shared _______ of the problem.

Answer 33

Understanding

Question 34

Interview sequence: _________ a plan.

Answer 34

Negotiating

Question 35

Interview sequence: Planning for ________ and ________ the interview.

Answer 35

Follow-up & closing

Question 36

Interview Strength: Used _______ and allowed patient to _______.

Answer 36

Open ended. Talk.

Question 37

Interview Strength: Used ________, ________ and ________.

Answer 37

Facilitation, Clarification/Repetition and Summary

Question 38

Interview Strength: _________ led patient to remember certain symptoms or health history.

Answer 38

Pertinent questions

Question 39

Interview Strength: ________ & ________ approach.

Answer 39

Nonjudgmental & Nonthreatening

Question 40

Interview Strength: Asked for ______ & about patient's ________.

Answer 40

Questions. Concerns.

Question 41

Interview Strength: _________ plans. Time for ________.

Answer 41

Well-explained. Patient education.

Question 42

Interview Strength: Make environment as ________ and _______ of distractions as possible.

Answer 42

Private & Free

Question 43

Interview Strength: Never make ________.

Answer 43

Assumptions

Question 44

Interview Strength: ________! Follow leads given by the patient asking more _______.

Answer 44

Listen. Direct question.

Question 45

Interview Strength: Be aware of both ________ and ________ cues from patient & relatives. And beware of your _______ as well.

Answer 45

Verbal & Non-verbal. Own.

Question 46

Interview Strength: Be aware of your _________ and _________ at all times.

Answer 46

Appearance & Professionalism

Question 47

The more you know, the more _______ your history becomes.

Answer 47

Pertinent

Question 48

Let urgency of the patient's condition be your ______.

Answer 48

Guide

Question 49

Documentation of patient's medical history and care.

Answer 49

Medical chart/record

Question 50

For record of patient's current status, communication with other parties involved in patient's care, continuity of care, quality assurance, education and research. Always consider patient's confidentiality.

Answer 50

Medical chart/record

Question 51

Guide for Ethics and Professionalism

Answer 51

Tavistock Principles

Question 52

Tavistock Principle: People have a right to health and healthcare

Answer 52

Rights

Question 53

Tavistock Principle: Care of individual patients is central, but the health population is also our concern

Answer 53

Balance

Question 54

Tavistock Principle: In addition to treating illness, we have an obligation to ease suffering, minimize disability, prevent disease and promote health.

Answer 54

Comprehensiveness

Question 55

Tavistock Principle: Health care succeeds only if we cooperate with those we serve, each other, and those in other sectors.

Answer 55

Cooperation

Question 56

Tavistock Principle: Improving health care is a serious and continuing responsibility

Answer 56

Improvement

Question 57

Tavistock Principle: Do no harm

Answer 57

Safety

Question 58

Tavistock Principle: Being open, honest and trustworthy is vital in health care

Answer 58

Openness