Medical Interview 101

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Transcription:

Medical Interview 101 Aekarach Ariyachaipanich, MD Division of Cardiovascular medicine 13.06.2017 Disclosure: I am not an English teacher Medical Interview 101 A D A P T F R O M P R E S E N TAT I O N O F DR. PATC H AYA B O O N C H AYA A N A N T E N D O C R I N E, M D C U Introduce yourself Hello Mr/Ms (lastname). My name is Dr (lastname) I am an Internist/general practitioner at Chief complaint (PC) What can I do for you today? What brought you to the hospital? What is bothering you right now? (Should you wish to take notes, ask the patients permission to do so) 1

LODCRAFT : Approach to chief complaint Location Onset Duration Characteristics Refer(region) Association symptom Factor(+/-) Time History of presenting illness (HPI) Site: Onset: Time course: Character: Where exactly is the pain? Can you show me where the pain is? When did it star was it constant/ intermittent, gradual/sudden? Does it come and go? How long has it been going on? Does it follow any time pattern? How long did it last? What is the pain like e.g. sharp, burning, tight? History of presenting illness (HPI) Radiation: Associations: Does it radiate/move anywhere? Is there anything else associated with the pain? e.g. sweating, vomiting Exacerbating/relieving factors: Severity: Does anything make it better or worse? How severe is the pain, consider using the 1-10 scale? Past medical history (PMH) What medical problems or illnesses have you had in the past? Tell me about the past hospitalizations and surgeries. Are you taking any medications? Anything over-the-counter? herbal medicines and/or health foods? How often are you taking it? (once-a-day, twice-a-day ) Any allergies? Food or medications? What kind of reactions? Family History Please tell me about any illnesses that may run in your family. Personal and Social History Do you drink, smoke, or use other drugs? Have you ever (smoked)? How many cigarettes per day? 2

Personal and Social History Are you single, married, widowed or divorced? Do you have children? Are you currently sexually active? (have you ever been.?) In the past 12 months, how many sex partners have you had? Male, female or both? Do you use protection? All of the time? Personal and Social History Whom do you live with? What do you do for work? Review of Systems Skin: any skin problems? rash? itch? sores? moles? Eyes: eye problems? vision loss? itchy eyes? blurry vision? double vision? Ears, nose, mouth, sinuses, and throat: any trouble with your hearing, ears, mouth, sinuses, or throat? Lungs: any lung or breathing problems? coughs? chest pain? Heart: heart problems? racing heart? skipping beats? Review of Systems Digestive: stomach problems? stomach pain? nausea? vomiting? diarrhea? constipation? bloating? blood in stool? Genitourinary: trouble with urinating? unusual color or smell? sexual problems? Menstrual peroid/cycle? Hematologic: easy bruising or bleeding? Endocrine: feeling too cold or too hot compared to others? excessive thirst, hunger, or urination? Review of Systems Musculoskeletal: problem with your joints or muscles, such as pain, swelling, weakness? Neurological: weakness, numbness, or tingling in arms or legs? problem with walking or balance? memory problems? headaches? seizures? Psychiatric: anxiety? depression? Patients do not understand medical terms MEDICAL TERM Sputum Trachea Axilla Defecate Feces NON-MEDICAL TERM Phlegm Windpipe Armpit Bowel movement Stool 3

Patients do not understand medical terms MEDICAL TERM Rhinorrhea Dyspepsia Tetany Myalgia Diplopia Tinnitus NON-MEDICAL TERM Runny nose Indigestion/heart burn Muscle cramps Muscle aches Double vision Ringing in the ear Paraphrase I see I understand that you are in pain Let me summarize Physical Examination Now I'll do your physical exam. (Wash your hands) Now I m going to Let me look at your joints listen to your heart and lungs feel your neck for any swollen glands tap your stomach Physical Examination I would like you to Could you please close your eyes take a deep breath in and out swallow sit up/lay down/stand up do this Physical Examination Just relax Just breath normally I m going to press/palpate Let me know if it hurts. At the end of the session Summary the history and PE I think/believe that you may have Let me run some test I m going to give you 4

Extra notes on history taking Give patient attention Use langue that patient understand Let patient talk Open question first, close question later Clarify the meaning of the term - Reflex back Actively listening Minimum note taking Professionalism o Knock the door o Wash your hand o Introduce yourself o Explain why are you there o Listen attentively o Aware of Multicultural standard o Firm hand shake o Maintain eye contact You can do it! Learn like a baby Listen talk Speak slowly Learning by doing Practice & practice Quick tips to fake it 1. Speak with confident In this world non-native speakers > native speakers 2. the last sounds esp. SSSSSS Appendicitis, football, cast, etc. 3. Open the dictionary for phonetic May not sound like it looks. Stomach, ischemia, syncope, vitamin 4. Stress and intonation A- na-to-my Med-i-cine Youtube https://www.youtube.com/watch?v=azbpmkicd7i https://www.youtube.com/watch?v=mzoebjyvle0 Etc. 5

Patch Adam 1998 6

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