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The Skills of History Taking (for Medical Students and Practitioners)
Rahul Tanwani
CHAPTER 1:
An Approach to the Diagnosis
SYMPTOM, SIGNS AND THE DIAGNOSIS
IMPORTANCE OF HISTORY TAKING
ROLE OF COMMUNICATION SKILLS
PILLARS OF HISTORY TAKING
What to Ask?
Why to Ask?
How to Ask?
Medical students vs Medical Practitioner
ROLE OF INVESTIGATIONS
CHAPTER 2:
Student-Patient Communication
THE MEANING OF BEING A PATIENT
STUDENT-PATIENT INTERACTION
Know About the Disease
How Do You Look?
First Impression
Proper Time and Place
Sit on a Chair
The Accompanying Persons
Begin with the Problem
Avoid Checking the Documents
Keep Addressing with Proper Words
Avoid Questions with Obvious Answers
Nonverbal Communication
Gestures
Facial Expressions
Eye Contact
Volume of Speech
Listen Actively
Use Appropriate Language
Local Terminologies
Do not Expect Prompt Answers
How to Write?
How to Conclude?
Follow-up
CHAPTER 3:
Format of Case History
WHY TO ASK?
RELATIVE SIGNIFICANCE OF QUESTIONS
OPTIMUM EXTENT OF ENQUIRY
HOW DOES THE PATIENT FEEL?
RELEVANCE OF INFORMATION
PROPER METHOD DURING STUDENT LIFE
CHAPTER 4:
Patient's Profile
NAME
AGE
SEX
RESIDENCE
RELIGION
OCCUPATION
SOCIOECONOMIC STATUS
CHAPTER 5:
Presenting Complaints
THE MEANING OF PRESENTING COMPLAINTS
SINGLE DISEASE: MULTIPLE SYMPTOMS
UNUSUAL ANSWERS
DURATION OF COMPLAINTS
HOW TO PRESENT THE SYMPTOMS?
CHAPTER 6:
History of Presenting Complaints
ONSET OF THE DISEASE
Course (PROGRESSION OR REGRESSION) OF THE DISEASE
CHARACTERISTIC FEATURES OF MAJOR SYMPTOMS
TREATMENT HISTORY
NEGATIVE HISTORY
Elicitation of History of Presenting Complaints
How to Ask?
How to Write?
Role of Language
Open-ended Questions vs Closed Questions
How to Present?
CHAPTER 7:
Past History
History of any Significant Disease
Tuberculosis
Diabetes
Hypertension
History of hospitalization
History of any Surgery
History of any other Significant Event
History of Similar Complaints in Past
CHAPTER 8:
Personal History
SLEEP
APPETITE
DIET
WEIGHT CHANGE
ADDICTION
Smoking
Tobacco Chewing
Alcohol
Other Addictive Substances
BLADDER AND BOWEL HABITS
MARITAL STATUS AND CHILDREN
CHAPTER 9:
Family History
HISTORY OF CONTACT
CHAPTER 10:
Menstrual and Obstetric History
MENSTRUAL HISTORY
Importance of Last Menstrual Period (LMP)
To Make a Diagnosis
To Plan the Investigations
To Plan the Treatment
OBSTETRIC HISTORY
CHAPTER 11:
Drug History
Commonly used drugs
Drugs for the same disease
Important to remember
CHAPTER 12:
Allergy History
CHAPTER 13:
Elicitation of Pediatric History
PATIENT's PROFILE
PRESENTING COMPLAINTS
HISTORY OF PRESENTING COMPLAINTS
PAST HISTORY
ANTENATAL HISTORY
BIRTH HISTORY
NEONATAL HISTORY
DEVELOPMENTAL HISTORY
DIETARY HISTORY
IMMUNIZATION HISTORY
FAMILY HISTORY
CONTACT HISTORY
ALLERGY HISTORY
CHAPTER 14:
Special Cases
PEDIATRIC PATIENTS
FEMALE PATIENTS
ELDERLY PATIENTS
TALKATIVE PATIENTS
RETICENT PATIENTS
IRRITATED PATIENTS
DISTRESSED PATIENTS
EDUCATED PATIENTS
EMERGENCY PATIENTS
ACCOMPANYING PERSONS
CHAPTER 15:
Presentation of a Case History
HISTORY TAKING DURING THE CLINICAL POSTING
HISTORY TAKING DURING THE PRACTICAL EXAMS
A Tensed Period of Life
Unpredictable Case
Limited Time Period
Unknown Examiner
Uncooperative Patient
PRESENTATION OF A CASE HISTORY
First Impression
Remember the Standard Format
Finish in Time
Do not Address by Diagnosis
Present as a Speech
Do not be a Translator
Present in a Moderate Speed
Be Prepared for Every Pattern
Minor Mistakes
Language
Avoid Doubtful Presentation
Cross-questioning of the Patient
Frequently Asked Questions
Focus on the Basics
Do not be Theoretical
COMMON MISTAKES
CHAPTER 16:
Communication Skills During Internship and Postgraduation
COMMUNICATION SKILLS DURING INTERNSHIP
COMMUNICATION SKILLS DURING POSTGRADUATION
The Looks Matter a Lot
Brief History and Presentation
Maintenance of the Working Place
Documents
Ward Rounds
Attitude Towards the Patients
Attitude with the Junior Staff
Academic Activities
Personal Life
CHAPTER 17:
Communication Skills in Clinical Practice
COMMUNICATION IN A PRIVATE CLINIC
Receptionist
Waiting Room
Consultation Room
First Impression
Avoid Scanning Old Documents
Start with Relevant Questions
Listen to the Patient Actively
Do not Defame the Others
Do not Disrespect Rituals and Beliefs
Explain About the Disease
Proper Choice of Investigations
Explain the Role of Investigations
Check the Reports Properly
Explain the Steps of Management
Explain the Outcome
Expenditure and Duration of Stay
Write a Clear Prescription
Photographs
Conclude the Session
COMMUNICATION DURING HOSPITAL VISIT
Be Punctual for Rounds
Knock the Door
Introduce Yourself
Maintain Privacy
Avoid Prolonged Discussions
Control Your Expressions
Do not Comment Upon Other Physician's Opinion
CHAPTER 18:
An Illustration of History Taking and Presentation
INDEX
TOC
Index
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