Case history taking

Communication with surgical patients (Surgical history taking)

Objectives

• Define effective history taking
• Describe components of patient history
• Outline patient interviewing techniques
• Identify strategies in obtaining history
• Techniques facilitating History Taking
• Special challenges

What is it?

• Patient interview in systematic way to:
• Recording necessary medical information
• + Classical examination signs
• All information must be documented precisely and accurately

Importance

• Help for reaching diagnosis
• Help in formulation treatment plan
• Evaluate medical progress
• Medico-Legal record
• Availability of information for:
• Research
• Reportable diseases
• Insurance claims

Example

• What the disease of that patient?
• Which body system is affected?
• Since when disease started?
• What treatment he received & does it help?

Types of patient interview

• Initial history taking
• Inward daily round: progress of condition, results of investigations, respond to treatment
• Discharge interview: plain at home
• Follow up visit: New symptoms & signs since last visit, drug management
• Field research or screening questionnaire

General rules

• Not just completing a form
• Tell patient your name and explain why you are seeing him
• More important for medical students
• Could be started before patient’s talk
• Give patient whole your attention
• Doctor should be an empathetic listener

Consent

• Type of consents:
• Oral
• Behavioral
• Written consent
• Why:
• To get adequate information about case
• Avoid medico-legal complains

Set the stage

• Provide safe environment
• Your behavior and appearance
• Shake hands
• Avoid the patient’s personal space
• Inquire about patient’s feelings
• Avoid unfamiliar or street terms
• Note taking
• Signs of uneasiness