Reflection
- Submitted by: penman
- Views: 452
- Category: Science
- Date Submitted: 10/21/2014 11:54 AM
- Pages: 26
- Report this Essay
describe each med model for each strand of history taking is important to the clinician in making a diagnosis
2000 words?
Sub headings
Start 200 words
Main 1500 words
Conclusion 300 words
History Taking
Taking history from a patient is a skill necessary for examinations and afterwards as a practising doctor, no matter which area you specialise in. It tests both your communication skills as well as your knowledge about what to ask. Specific questions vary depending on what type of history you are taking but if you follow the general framework below you should gain good marks in these stations. This is also a good way to present your history.
Subject steps
1. Introduce yourself, identify your patient and gain consent to speak with them. Should you wish to take notes as you proceed, ask the patients permission to do so.
2. Presenting complaint (PC)
This is what the patient tells you is wrong. E.g. chest pain
3. History of presenting complaint (HPC)
Gain as much information you can about the specific complaint.
Sticking with chest pain as an example you should ask:
• Site: Where exactly is the pain?
• Onset: When did it start, was it constant/intermittent, gradual/ sudden?
• Character: What is the pain like e.g. sharp, burning, tight?
• Radiation: Does it radiate/move anywhere?
• Associations: Is there anything else associated with the pain e.g. sweating, vomiting
• Time course: Does it follow any time pattern, how long did it last?
• Exacerbating/relieving factors: Does anything make it better or worse?
• Severity: How severe is the pain, consider using the 1-10 scale?
The SOCRATES acronym can be used for any type of pain history.
4. Past medical history (PMH)
Gather information about a patients other medical problems (if any).
5. Drug history (DH)
Find out what medications the patient is taking, including dosage and how often they are taking them e.g. once-a-day, twice-a-day, etc.
At this point it is a good idea to find out if the patient...
2000 words?
Sub headings
Start 200 words
Main 1500 words
Conclusion 300 words
History Taking
Taking history from a patient is a skill necessary for examinations and afterwards as a practising doctor, no matter which area you specialise in. It tests both your communication skills as well as your knowledge about what to ask. Specific questions vary depending on what type of history you are taking but if you follow the general framework below you should gain good marks in these stations. This is also a good way to present your history.
Subject steps
1. Introduce yourself, identify your patient and gain consent to speak with them. Should you wish to take notes as you proceed, ask the patients permission to do so.
2. Presenting complaint (PC)
This is what the patient tells you is wrong. E.g. chest pain
3. History of presenting complaint (HPC)
Gain as much information you can about the specific complaint.
Sticking with chest pain as an example you should ask:
• Site: Where exactly is the pain?
• Onset: When did it start, was it constant/intermittent, gradual/ sudden?
• Character: What is the pain like e.g. sharp, burning, tight?
• Radiation: Does it radiate/move anywhere?
• Associations: Is there anything else associated with the pain e.g. sweating, vomiting
• Time course: Does it follow any time pattern, how long did it last?
• Exacerbating/relieving factors: Does anything make it better or worse?
• Severity: How severe is the pain, consider using the 1-10 scale?
The SOCRATES acronym can be used for any type of pain history.
4. Past medical history (PMH)
Gather information about a patients other medical problems (if any).
5. Drug history (DH)
Find out what medications the patient is taking, including dosage and how often they are taking them e.g. once-a-day, twice-a-day, etc.
At this point it is a good idea to find out if the patient...